Surgery isn't always the best option 

click to enlarge Some doctors choose surgery before considering other options including rehab.

Some doctors choose surgery before considering other options including rehab.

"Surgery can make you worse."

That's a tough statement from an orthopedic surgeon who loves to help people get better. I spend most of my life either rehabilitating people from injuries or arthritis or repairing injuries and replacing cartilage to fix the arthritis.

In all of this, I recognize that if I can get people better without surgery, it's better. Yet I also see many cases where it is far more conservative to repair the damage early, rather than wait until the damage is too great, such a torn meniscus or a missing meniscus that should be replaced before arthritis sets in.

So why the dire warning?

Because stuff happens and each person heals a little differently. Sometimes the best efforts to repair a problem can in fact make it a lot worse. Let's look at some of our worst nightmares.

Infection: Fortunately in our hands, infection is rare, less than 0.2 percent of our cases. Yet when it does occur, it can vary from being just an annoyance to being devastating. Despite all the best-practice efforts to avoid an infection — washing the affected site the night before surgery, giving a preventive antibiotic before the surgery starts, to extreme sterility in the operating room, sealing all wounds with wound glue, careful wound care in the post-operative period — unfortunately, some patients will still grow an unwanted organism.

Why? Currently, the thinking is that, absent an obvious break in sterility, some patients naturally harbor organisms on their skin that when given the chance will grow in a surgical site. Some patients have immune systems that fail to overwhelm some bacteria. And some patients just have a temporary reduction in bacteria-fighting ability, possibly related to the stress of surgery. We counsel our patients that we can treat, and most of the times fully repair, the damage done by an infection, if noticed and treated early. Attention by the medical team and the patient's attitude make a huge difference in the success of the treatment. An upbeat patient brings good, healing thoughts to their own body and to the team caring for them, which definitely seems to improve the outcome.

Blood clots: Many people naturally form small blood clots after extremity trauma or surgery. The body seems to dissolve these naturally. Some clots, especially those in the large vessels behind the knee, can cause real problems by migrating to the lungs. Preventive measures such as a daily aspirin, immediate weight-bearing and lower-leg exercises, avoiding braces and casts that might pinch the leg clearly help diminish the incidence of clots. Having the surgical and rehabilitation team carefully monitor the patient helps diagnose the clots early, usually by ultrasound, and treat those that need to be treated avoiding the secondary complications. Novel genetic testing may soon be widespread enough to help predict which patients will clot.

In our practice, a patient with a genetic screen from 23andme highlighted their risk of clotting and because the rehab team was aware of the genetic profile, an early serious clot was caught, treated and the patient's life saved.

Scar tissue: Some patients form more scar tissue than others. Careful handling of the tissues at the time of surgery can diminish the scarring, but not always. Immediate frequent manual physical therapy definitely diminishes the scar formation and preserves joint motion even in the high scar formers. Despite this, some patients will go on to lose joint motion and require further measures. Scars are the enemy of a great outcome for most orthopedic surgery and novel efforts to reduce it are coming. Certain injections of scar-reducing compounds may help more in the near future than they are able to today. For now, optimizing the surgery, rehabilitation and pushing for early motion for almost all injuries and surgery makes the difference.

Pain: The goal of repairing injuries, replacing missing tissue or putting in an artificial joint replacement is to relieve pain and restore function. Our goal for our patients is to return them fitter, faster and stronger than they were before they were hurt so our care doesn't stop just at the end of the physical therapy sessions but continues throughout the conditioning and fitness stages.

However, unless pain is relieved, progress cannot happen. The best pain strategies today involve preventive anesthesia, which means loading the patient up with numbing medications before an incision is made, preventing the brain from ever getting the pain signals. We have our patients wake up from surgery with numb joints usually lasting 24 to 48 hours. Then when the ache does come on, it is more manageable with pain medications. We use Tylenol and Toradol first and narcotics only if needed, since they make patients nauseated.

While almost all patients get adequate pain relief early, if they have pain during or after the rehab process or worse — if the surgery fails to remove the pain that they came to the doctor for — then the patient and the doctor are very unhappy. Surprisingly, data recently noted that up to 50 percent of patients with artificial knee joints still had pain two years later. This is clearly unacceptable and significant improvements in both joint replacement and all surgical procedures need to be made to overcome the pain problem.

Aside from a problem with the actual joint, pain can come from a variety of sources and can be treated in many ways. Our attitude is to encourage patients to use what ever means work. Acupuncture works for some patients and not others, massage works for some, increasing rather than decreasing exercise works to reduce pain for some.

The worst treatment is chronic use of narcotics or muscle relaxants, which create a dependency that debilitates both the muscle and the mind of the patients. Novel pain treatments are on the way with both long acting local anesthetics and brain wave treatments that may alter the perception of pain centrally.

So surgery can make you worse. Fortunately, most of the time it can make you significantly better but we must all be prepared for the worst case and be ready to act.

Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments. For more info, visit www.stoneclinic.com.

About The Author

Dr. Kevin R. Stone

Bio:
Dr. Kevin R. Stone is an orthopedic surgeon at The Stone Clinic and chairman of the Stone Research Foundation in San Francisco. He pioneers advanced orthopedic surgical and rehabilitation techniques to repair, regenerate and replace damaged cartilage and ligaments.
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