Matthew Solan
LFAC Consultant
In modern medical practice, surgery is often seen as a decisive and curative action; a means to resolve serious medical conditions or injuries. However, the wisest doctors and surgeons adopt a cautious approach. Surgery is a last resort rather than a first-line solution. This approach, which is often referred to as surgical reluctance, reflects the complexity of surgery itself, the potential for complications, and the overarching goal of improving patient outcomes with minimal intervention.
While surgery can be transformative (not often life-saving in orthopaedics), it also carries inherent risks and prolonged recovery periods. Patients very often consider that “routine operations” are 100% safe and free from trouble. If only…..
I was once asked, when outlining the nature of the incision/scar, how long it would remain there. “Forever” was met with total incredulity. As if humans heal like aliens in the cinema!
Due to risks and prolonged recovery, after foot and ankle operations in particular, it is almost always preferable to explore conservative treatments or alternative methods first.
“I have tried physio” should always be challenged. Which exercises? For how long? How frequently? These questions reveal many inadequacies – either that the physical therapy was no more than a rub-down, or that life was just too busy to comply with the program.
If a splint or insole doesn’t help sufficiently you can throw it away and start again. Once an operation is done there is no going back.
Surgery should be considered only when all other options have been thoroughly explored and properly exhausted.
Surgery is often premature because of a failure of proper conservative treatment.
The Philosophy of Surgical Reluctance
Surgeons, despite our training in operative techniques, are primarily diagnosticians. Wise surgeons are the ones who recognise the limits of their treatments. Experience counts in this regard.
“It takes ten years to learn how to operate.”
“It takes another ten to learn when to operate….”
“…and ten more to know when not to operate”
Beware youngsters with fancy tricks.
“My GP said to come and see you because you are busy and so you will not always operate” was (I think?) a compliment of sorts.
- First, Do No Harm (Primum Non Nocere)
For surgeons, this means weighing the risks and benefits of each procedure carefully. Surgery, by its nature, is invasive and disruptive. Even when performed perfectly, it can have unintended consequences. Therefore, sensible surgeons prefer to avoid surgery if less invasive treatments, such as medications, physiotherapy, or lifestyle modifications, can achieve a similar result.
- Patient-Centered Care
A patient-centered approach to medicine focuses on what is best for the patient as a whole, rather than simply addressing a particular disease or condition. This holistic view takes into account not only the physical aspects of the patient’s health but also their psychological, emotional, and social well-being.
A reluctant surgeon prioritises long-term patient outcomes and quality of life. Non-surgical treatments can avoid the stress, anxiety, and potential trauma that accompanies surgical procedures.
- The Body’s Healing Capabilities
The human body has a remarkable capacity to heal itself. In many cases, conditions such as sprains, strains, minor fractures, or soft tissue injuries will resolve with time, rest, and rehabilitation. Surgeons should understand, though sadly many forget, that intervening too early or too aggressively can sometimes do more harm than good, interfering with the body’s natural healing processes. By allowing time for recovery and employing less invasive treatments, many conditions improve without the need for an operation. Evidence based medicine is important here, and over the last 10 years, well-structured UK National studies have shown that Achilles tendon ruptures, many ankle fractures and calcaneal fractures seldom need repair. Mother Nature vs Surgeon. No contest.
- Avoiding Unnecessary Risks
All surgeries, no matter how routine or minor they may seem, carry risks. These include anesthesia-related complications, post-operative infections, blood clots, and unintended damage to surrounding tissues. In addition, surgery often requires a significant recovery period during which patients may experience pain, limited mobility, and a temporary decrease in quality of life. A reluctant surgeon carefully assesses whether the benefits of surgery truly outweigh these risks.
Quoting risks in percentage terms is, for many patients, unhelpful. Even if the risk is 1% that can mean a whole lot of 100% trouble if you are the unlucky patient.
The Role of Alternative Treatments
One of the key reasons why surgery is a last resort is the wide array of alternative treatments available for many conditions. Modern medicine offers a plethora of non surgical interventions that can alleviate pain, improve function, and promote healing without the need for invasive procedures. These alternatives are typically explored before surgery is considered.
However, evidence should prevail here too. There is simply no convincing evidence that “modern injection therapies” like PRP have a useful role. “Product Rich in Placebo”?
- Supports
Expert advice regarding shoes, insoles and braces can transform foot and ankle complaints. Having a network of colleagues in podiatry and appliances is imperative to excellent foot and ankle care.
- Physiotherapy
Physical therapy is a cornerstone of conservative treatment for musculoskeletal issues. Targeted exercises, stretching, and manual therapies allow physiotherapists to help patients regain strength, flexibility, and function. In many cases, physiotherapy can resolve or significantly improve conditions that might otherwise lead to surgery.
Appropriate imaging investigations are essential to provide an accurate diagnosis, and guide the physio. Achilles tendon pain will respond to stretching regimens in 95% of cases when the problem is in the main body of the tendon. However, if the pathology is just a little lower down (where the tendon attaches to the bone) then the very same exercises are almost certain to aggravate symptoms. Attention to detail and diagnosis are the first steps to successful non-operative treatment.
- Lifestyle Modifications
For chronic conditions, such as cardiovascular disease, diabetes, or obesity, lifestyle modifications are often the first line of treatment. These changes can include dietary adjustments, increased physical activity, and smoking cessation. Some surgeons gloss over these lifestyle modifications when “a routine operation” is seen as an easier option and a quick fix. Weight-loss conversations are easy to avoid.
Over a 2-year period a nursing colleague had innumerable treatments to try and help her plantar fasciitis. She stopped coming to clinic, but I saw her in the corridor and the conversation turned to her feet. “Glad to hear you are better – which of my clever treatments helped in the end?” Reply: “None of them. What helped most was losing three stone”. Important reminder.
- Minimally Invasive Procedures
In recent years, advances in technology have led to less invasive procedures that offer an alternative to traditional surgery. Techniques such as arthroscopic surgery and interventional radiology allow for the treatment of conditions with smaller incisions, less tissue damage, and faster recovery times. A reluctant surgeon will always opt for these less invasive methods when they are available and appropriate.
Until recently, any patient with a Morton’s neuroma that relapsed after a cortisone injection would – almost as an orthopaedic reflex – be offered surgical excision. Even though >10% of patients will be unhappy afterwards. Now there is the option of Radiofrequency Ablation, with the largest series of patients treated via LFAC clinicians. Local anaesthesia. Swift recovery. Success rates close to those of surgery. Yet not utilised in other centres.
Patient Involvement in Decision-Making
In recent years, there has been a growing recognition that patients should play an active role in their own healthcare decisions. This shared decision-making is particularly important when it comes to surgery. The surgeon presents ALL options for the patient to consider, with the pros and cons of each. Even treatments that they do not offer. Including the option of doing nothing.
- Informed Consent
Informed consent is a critical component of any surgical decision. Patients must be fully informed of the potential risks, benefits, and alternatives to surgery before agreeing to undergo a procedure. Careful surgeons, wisely reluctant to operate unless necessary, ensure that patients understand the full scope of their condition and the full range of available treatments, including non-surgical options and including doing nothing. This allows patients to make educated decisions about their care, rather than feeling “pressured into surgery” or hungry for a quick-fix.
- Setting Realistic Expectations
Surgery is not always a cure-all, and some patients have unrealistic expectations about what it can achieve. The reluctant surgeon takes the time to discuss the outcomes of surgery, including potential complications and the need for post-operative rehabilitation. This honest conversation helps manage patients’ expectations and often leads them to consider other treatment options first. Patients are surprised when warned that a well meaning operation can, sadly, sometimes produce no improvement or even occasionally make things worse.
- Exploring Patient Preferences
Not all patients are willing or able to undergo surgery, even if it is recommended. Some may have concerns about the risks, while others may not want to take time off work or face a lengthy recovery. A reluctant surgeon listens to the patient’s preferences and works with them to find a treatment plan that aligns with their goals and lifestyle. In many cases, this may mean pursuing less invasive treatments.
When Surgery Becomes the Only Option
Despite the preference for conservative treatment, there are times when surgery is the best or only option. In these cases, the reluctance to operate gives way to the necessity of intervention. Surgery may become the last resort for several reasons:
- Failure of Conservative Treatments
If all non-surgical treatments have been tried and failed to relieve symptoms or correct the underlying condition, surgery may be the only option. For example, a patient with chronic ankle pain who has not responded to physical therapy, medication, or injections may ultimately require ankle fusion or replacement surgery to regain mobility and reduce pain.
- Progressive or Degenerative Conditions
Some degenerative musculoskeletal conditions may worsen over time if left untreated. In these cases, delaying surgery could lead to more severe complications or reduce the likelihood of a successful outcome. A surgeon may recommend surgery as the best option to prevent further deterioration and improve the patient’s prognosis. A flexible flat foot, left too long, will eventually lead to ankle arthritis as a secondary consequence. Judging when to intervene is more art than science.
Conclusion
Surgery is a powerful tool in the medical arsenal, but is rarely the best first option. The wise and reluctant surgeon knows the importance of exploring all available treatments before resorting to surgery. By prioritising patient-centered care, minimising harm, and trusting Mother Nature, surgeons will usually achieve excellent outcomes without the need for invasive procedures.
When surgery is necessary, it is because all other options have been exhausted, and the benefits clearly outweigh the risks. A cautious, measured approach ensures that patients receive the best possible care while avoiding unnecessary complications and long recovery times. In a world where medical technology continues to advance, the philosophy of surgical reluctance reminds us that sometimes, less is more.
Surgery is often premature because of a failure of proper conservative treatment.
