No free lunch in orthopedics
No free lunch in orthopedics
Benjamin A. Goldberg 0 1
Marius M. Scarlat 0 1
0 Clinique St Michel , Toulon , France
1 Benjamin A. Goldberg
2 Marius M. Scarlat
“There is no such thing as a free lunch” is an adage that referred to the effect of patrons of a nineteenth century strategy used by liquor establishments in the United States to entice consumers to enter and have lunch without cost. However, customers would presumably on average purchase alcohol in sufficient quantity that it would be profitable for the liquor establishment despite serving food “for free”. Today, the term refers to the observation that one usually cannot get something of value without either an obvious significant financial or indirect cost or a non-obvious cost. One example of a non-obvious cost is a potential unrealized negative effect. In other words, one cannot get something for nothing. Charity is exempt from this basic exchange algorithm as charity is based on moral principles such as giving away for a better moral image or for a place in heaven.☺ In mathematical folklore, the "no free lunch" theorem of David Wolpert and William Macready is published in 1997 [1]. In computer programming, no free lunch has been demonstrated in theory that if something “performs well on a certain class of problems then it necessarily pays for that with degraded performance on the set of all remaining problems.” Orthopedic surgeons as well as other medical professionals have been blinded by the lure and possibility of a “free lunch” over the last several decades. The goal of orthopedic surgery should be to restore function, improve motion, minimize pain,
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University of Illinois, Chicago, IL, USA
or prevent a negative outcome such as loss of life or limb. For
example, a patient with an ACL deficient knee may
experience instability or diminished function upon sustaining a knee
ligament injury. Some patients undergoing ACL
reconstruction surgery may experience an obvious complication or
suboptimal outcome including infection, graft failure, or failure to
return to their prior level of sport. However, even if one
excludes these early obvious negative outcomes, long-term
consequences that may not be obvious early on in the
development of the procedure may include a higher rate of arthrosis in
the surgically reconstructed knee than if treated without
surgery. Problems with implants used in this type of surgery were
also described [
2
]. Commonly, there are technological
“advances” of a procedure or implant where some known
challenge or shortcoming of surgical reconstruction is
“improved”. For example, the traditional femoral stem of a hip
arthroplasty that has a fixed neck angle and anteversion
relative to the stem cross-sectional geometry cannot perfectly
anatomically reproduce normal lateral offset, limb length, and
version in most patients. Traditionally, compromises were
made intraoperatively with endoprosthetics to obtain adequate
stability and range of motion and limb length. Recently,
manufacturers “improved” design by allowing a new modular
junction between the stem and neck to try to improve
anatomical reconstruction and minimize implant inventory. The
manufactures were trying to “have it all” in terms of benefitting
patients and additionally likely improving profitability. This
advance allowed intraoperative alteration and
pseudocustomization of an implant to try to more naturally reproduce
anatomy. Even if one ignored the obvious economic downside
of increased cost of such implants to a health care system
(there is already a significant cost to this “meal”), short and
mid-term studies have demonstrated a significantly higher
failure rate than the prior generation prosthetics without such
modularity due to corrosion and metallurgical failure. This
anticipated “improvement” in patient outcomes and corporate
profitability did not materialize because it was not anticipated
that the non-obvious (at the time) improvement may be a
design or other flaw that could lead to costly litigation and
revision surgery. [
3
]. Other cases were related to a specific
implant design either in hip or shoulder, they are recognized
in the literature and the indications should be made with
caution with a clear logic of choice that include the possibilities of
failure [
4–7
]
Other “solutions” include trying to minimize a problem
(polyethylene wear) with metal-on-metal articulations, which caused
potentially a worse problem with metal ion disease. Shoulder
surgeons have seen surgical induced chondromalacia from
implants or chemical/medications placed in the shoulder or thermal
devices [
8
], failures from partial resurfacing arthroplasties [
4
],
knee surgeons have seen increased rates of revision of
unicompartmental arthroplasty [
9
], hand surgeons have seen
silicone failures [
10
].
Until recently, ankle arthroplasty was fraught with high
rates of loosening and revision [
11
]. Spine surgery has seen
tremendous advances in techniques in impla (...truncated)