For many patients, the question they are asking is whether or not to have surgery. This is a question many patients struggle with. When the discussion turns to surgery, the initial response from a patient is, "I don't want to have surgery." Surgery is never what we want, but sometimes it is not only necessary, but it is the right course of treatment. So that begs the question: When is surgery necessary, and when can it be avoided? Unfortunately, there are several things that need to be considered when making a decision about surgery.
When making a decision about surgery, the first thing to consider is whether you have tried some type of non-surgical treatment to reduce the pain, restore the range of motion and build up your strength of the painful or injured area. Unless the pain is the result of a direct trauma, it is unlikely that surgery will be the first alternative to fix the problem. Nonsurgical treatments such as ice, anti-inflammatories, physical therapy, chiropractic, etc. should be tried as the first line of remedy.
If nonsurgical treatment fails, it may be that there is an underlying anatomical cause that is beyond nonsurgical means. Injuries such as tendon tears that are considered full thickness, as in a rotator cuff tear, often require surgery to re-establish the anatomical integrity and restore normal function. While some patients can become pain-free with an existing rotator cuff tear, they rarely regain the strength and function that they had before the tear. Now, the decision regarding surgery becomes: Is the repair being performed to reduce pain or improve function? There are many nonsurgical methods of pain control, but in this scenario, surgical repair is the best option to restore function.
In the case of advanced osteoarthritis or degenerative joint disease, there are a few factors to consider. Pain is first and foremost. It could mean a reduction in function in the form of losing range of motion, or the inability to bear weight on the painful limb or even go up and down stairs normally. Non-surgical treatment has failed to reduce the pain and restore the function; an X-ray and/or an MRI has verified that the degeneration has reached a point that there would be no benefit to an arthroscopic surgery to "clean up" the joint. In this case, the best but probably not very desirable choice will be to have a total knee replacement. We commonly hear the phrase, "put it off as long as possible." Unfortunately, in the previous two examples, this is actually bad advice.
In the case of the rotator cuff tear, the longer you wait, the less likely the surgery will turn out well. Generally speaking, the repair should be performed within the first six months from the time of the tear. This gives the surgeon the best chance to create a good repair and the physical therapist the best chance to restore your range of motion and strength. So the sooner the status of the anatomy is established, the sooner the best decision can be made regarding the necessity of surgical repair.
When putting off a total knee replacement, the risk is continued loss of motion, the escalation of joint stiffness and onset of deformity. The problem with a stiffening, deformed, and arthritic joint is that once the knee replacement is performed it is difficult to regain the range of motion. Therefore, waiting "as long as possible" is not necessarily the best plan. Once the degree of arthritis or degeneration is established and your medical team feels that a total joint replacement is the most prudent option to reduce chronic pain and restore maximal function, it is a good idea to follow through with it. Yes, it will be tough in the early going, but your long-term benefit will be worth it.
Another common pre-operative treatment or attempt at avoiding surgery is the injection of some type of synthetic joint fluid, also known as viscosupplements. According to Dr. Jonathan Cluett, an orthopedic surgeon, "Numerous studies have investigated the effectiveness of various viscosupplements as a treatment for knee arthritis. Studies have ranged in their results from no benefit when compared to placebo injections, to mild improvement in symptoms. However, the larger, better-designed studies seem to show very little benefit with these injections." So while the scientific research does not pan out in favor of the injections, there is no physical downside, only a financial downside, because health insurance companies are denying coverage because of the poor response.
When making a decision about whether or not to have surgery, consider why you would have it — to relieve pain and/or restore function. Discuss this with your surgeon or health care team. Remember that it is OK to go for a second opinion if you are uncomfortable with the answers you are being given.