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What are the challenges and where next?

What surgery or other non-medical treatments involve

Open surgery for musculoskeletal conditions includes:

  • Joint replacement - where the damaged joint is completely replaced with an artificial joint.
  • Repairing fully torn tendons by reattaching them to bone, or partially torn tendons by scraping off scar tissue.
  • Joint fixation (surgically aligning and fixing broken bones with supportive implants such as plates or screws).

Many alternatives to open surgery have recently been investigated for relieving musculoskeletal conditions.

These include:

  • Keyhole - or arthroscopic - surgery, where the repair is done through a very small cut. There is less damage to tissue compared with open surgery, but it may be less easy for the surgeon to see inside the injury.
  • Conservative treatment, such as a sling (for upper arm fracture) or using an adapted plaster cast technique, such as close contact casting. Active rehabilitation is also part of the treatment.
  • Physiotherapy and exercise rehabilitation, which may be used on their own, to prevent or delay a need for surgery, or before, after or with other treatments.

Some of these options are adaptations of, or new uses for, existing techniques. For example, close contact casting was originally used in the diabetes field, where skin was very fragile and difficult to heal. Other approaches, such as individually tailored physiotherapy, are more about changing how the service is provided to make it more effective.

Why we need research into techniques

We’ve known for a long time how to use research to compare the effectiveness and safety of two medicinal treatments. Drugs are manufactured to uniform high standards, and it is relatively easy to dispense them in an objective way. That means there is a lot of evidence to inform medicinal treatments.

It is more difficult to design research to compare the effects of surgery and other techniques, such as physiotherapy or using a plaster cast.

Implants (such as artificial joints) are less regulated than drugs, and there is a lack of long term research on their safety. Techniques are even more difficult to regulate or study; surgeons and other therapists are part of the treatment and so their skill and confidence are important variables; there are issues in designing a control treatment (we are only beginning to understand how to carry out ‘sham surgery’); and patients will usually be aware of which treatment they are receiving - they often cannot be ‘blinded’ as in other types of trial.

Finally, it is impossible to generalise between procedures. For example, it is not necessarily the case that minimally invasive surgery is easier, creates a smaller scar or has a shorter recovery period. We need research on each procedure and its comparators, which may well be physiotherapy, conservative treatment or a waiting list.

Professor Andy Carr, principal investigator for the UKUFF trial, comments on the difficulties of researching surgery:

Dr Toby Smith, physiotherapist, comments on variables in physiotherapy research:

The developing research field: the role of NIHR

In the last ten years, the field of research into musculoskeletal surgery and its alternatives has grown and developed. This is the result of a coordinated effort from:

These initiatives have helped create agreement on how to describe and standardise treatments. Surgeons have also become more familiar with the requirements for participating in research.

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