Some treatments are withdrawn or pushed aside. Some diagnoses lack support or acceptance and fall out of favor. In orthopaedics, four glaring examples stand out:
1) Thermal capsulorrhaphy
2) Arthroscopic knee arthritis debridement (clean out)
3) Shoulder labral repair
4) Radiofrequency facet lesioning
Radiofrequency heat probes were promoted to shrink lax joint capsules predominantly in the shoulder to eliminate pain believed to be coming from shoulder instability. Conceivably this joint, which is akin to a saucer with a ball pivoting on it surrounded by powerful rotator cuff muscles, would benefit and is somewhat akin to tightening the waist of your slacks after a diet. In fact, any pain relief gained was probably achieved via nerve cell death by cautery. Many people who are subjected to this unwise, poorly conceived procedure ended up with worse problems- complete loss of joint capsule, persistence of pain and arthritis, etc.
Removal or repair of a torn meniscus, the firm, elastic cushions in each knee, results in pain relief in those in whom it is torn- usually after age 35. Many people over the age of 40, however, have degenerative arthritis in their knees. In fact, over a million total knee joint replacements are now done in the United States per year for arthritis. Some surgeons not savvy enough failed to note the lack of lasting pain relief in arthritic knee cases unless there was also a torn meniscus. Simply cleaning out or “debridement” of knees with degenerative wear does not significantly benefit most patients. When the soreness from the surgery would wear out upon resumption of normal activity, pain, swelling and stiffness from the arthritis is again experienced.
Shoulder labral repair seems to be another fad. The glenoid labrum is a retaining band usually circumferentially around the glenoid or the “socket” of the shoulder which is only rarely significantly torn or pulled loose. The diagnosis of a torn glenoid labrum was first made with introduction of arthroscopy of the shoulder in the 1980s. In the early 2000s, however, it has been mis-diagnosed frequently with treatment offered in the form of insertion of anchors arthroscopically to secure the lax tissue. However, even the “experts” can’t agree on what is and is not torn. Notably, however, only about 60% of the people carefully monitored after alleged labral repair seem to benefit from it. Many are made worse, so much so that because of postoperative stiffness it is recommended against in those that are over 40 years old- the most likely to have one. It has been well-established since the early 1970s that the overwhelming majority of adult shoulder pain results from a condition known as impingement. Unless a person undergoes an impingement procedure at the same time of undergoing their alleged labral repair for what is probably not even torn, he is unlikely to benefit. Open or arthroscopic acromioplasty with or without outer collarbone removal, i.e. lateral clavicle resection, yields about a 90% good or excellent result. This is with ignoring a labrum. Stephen Weber, MD, has been crying about this for a number of years now.
Radiofrequency lesioning of nerves (RFLG) is a procedure made possible via careful and anatomic dissections by Swiss and German anatomists years ago. Radionics manufactured the electrode device allowing cautery of selected nerves along the spine. and is used predominantly in the spine. It makes sense that if we can eliminate the messenger of pain to the brain from an area of inflammation or decay that patients will quit complaining of pain and improve his function. In fact, there is only a very small percentage of people who meet the criteria with which to benefit from this procedure. The problem with the RFLG probes is that they are widely distributed to anyone with an MD wishing to offer the care. Herein lies the issue. The technique is applied via a needletip cautery probe usually under x-ray control down to the area of discomfort. In order for RFLG to work the needle needs to come into direct or nearly contact with the nerve ending in question. The technique is most applicable to small facet joints in the back of the swine. However, the majority of people who have spine decay exhibit it both anteriorly, i.e. in the front of the spine in the disks, and posteriorly in the facet joints, so RFLG is only able to treat those portions of the back or the spine. To benefit, it must be established if a given patient has a majority of their discomfort coming from the posterior part of the spine rather than the front part. The simple test for this is to see whether they hurt mostly or exclusively when leaning backwards rather than when they lean forward. A person if hurting when they lean forward is not a candidate for this procedure. This includes the majority of people with acute and chronic low back pain. When applied to a patient who meets the criteria, the success rate is high but the case load is small. When applied indiscriminately as is being done by pain management doctors, there is a very high failure rate. These same doctors allege that the nerve endings are just growing back- I don’t think that is the case. The technique is just being applied to the wrong people. One would have to do an awful lot of extremely damaging dissection research on animals to confirm the nerve endings that are regenerated.
Laser has pretty much run its course so far. It has been a technology craving for appreciation outside of industrial use. A laser is just a hot knife in surgery. It has found a place predominantly in eye surgery because the laser beam, a form of light, can go through the lens to different portions of the eye without using a knife if can be directly very carefully. It has limited use in otolaryngology for trimming lesions of the vocal cords. There is very little room to work and direct vision can be achieved. Elsewhere it really has no great value. Companies try and come up with devices to make money and promote a procedure with which to use their equipment. There is just very little use for a “hot knife”. This is a very expensive gimmick to draw people in. Patients think they are getting the newest and greatest and unfortunately it increases the cost considerably without added benefit.
The worst-case scenario is use of a laser for arthroscopic arthritic knee debridement- I’ve seen it done in S.F.!
In general, a doctor should not strive to be the first to offer poorly conceived treatment lacking from foundation on research.
 Franceschi, Francesco, Guiseppe Longo, Umile, Ruzzini, Laura, Rizzello, Giacomo, Maffulli, Nicola and Denaro, Vincenzo. “No advantages in repairing a type II superior labrum anterior and posterior (SLAP) lesion when associated with rotator cuff repair in patients over age 50. A randomized controlled trial.” The Am Journ Sp Med, Vol. 36, No. 2, pg 247+.
Leahy, Maureen. “When SLAP repairs fail.” JAAOS article examines challenges surrounding diagnosis and management. AAOS Now, September 2014.
Gobezie, Reuben, Zurakowski, David, Lavery, Kyle, Millett, Peter J., Cole, Brian J., and Warner, Jon P. “Analysis of interobserver and intraobserver availability in the diagnosis and treatment of SLAP tears using the Synder Classification.” Am Jour Sp Med, Vol. 36, No. 7, pg. 1373+.
Weber, Stephen C. “Surgical management of the failed SLAP repair.” Sports Med Arthr Rev, Vol. 18, No. 3, September 2010.
Katz, Laurie, Hsu, Stephanie, Miller, Suzanne L., Richmond, John C., Khetia, Eric, Kohli, Navjot, and Curtis, Alan S. “Poor outcomes after SLAP repair: Descriptive analysis and prognosis.” Arth: Journal of Arth & Related Surg, Vol. 25, No. 8 (August), 2009: pp 849-855.
 Weber, MD, Payvandi, DO, Soheil, and Martin, MD, David F. “A worrisome trend in SLAP repair.” AAOS Now, August 2010.