Surgery versus conservative care: when does the operation earn its place?

International expert consensus on operative versus non-operative management of ACL injury: reconstruction is not mandatory for everyone, and a trial of structured rehabilitation is appropriate for many patients, with reconstruction favoured for persistent instability or high-demand pivoting sport.

• Reconstruction is not mandatory after every ACL tear; a structured rehabilitation trial is a legitimate first option for many patients.
• Surgery is favoured where instability persists despite rehabilitation, or for a return to high-demand pivoting or contact sport.
• The route is a shared decision, weighing activity goals, instability, concomitant injuries and patient preference.

Our appraisal: Structured expert opinion (66 clinicians across 18 countries, modified Delphi), not a randomised comparison, so it standardises how the operative-versus-conservative decision is framed rather than proving one route superior. Its practical value is permission to individualise: it legitimises a rehab-first pathway that everyday practice often skips.

A GRADE-based clinical practice guideline making a strong recommendation against subacromial decompression surgery for atraumatic, rotator-cuff-related shoulder pain.

• The panel makes a strong recommendation against subacromial decompression surgery for subacromial pain syndrome.
• Evidence from randomised trials, including sham-surgery comparisons, shows no important benefit over placebo surgery or exercise-based care.
• Exercise and conservative management should be the default; surgery does not add meaningful benefit for atraumatic shoulder pain lasting more than three months.

Our appraisal: Unlike most consensus documents this is an explicit GRADE guideline anchored to randomised and sham-controlled evidence, so the strong recommendation carries real weight rather than expert opinion alone. It is a clean example of a common operation losing its place once placebo-controlled trials are done.

European expert consensus on when, if ever, arthroscopic surgery is warranted for degenerative meniscus lesions, developed from a literature review and structured expert agreement.

• Arthroscopic partial meniscectomy should not be a first-line treatment for a degenerative meniscus lesion; supervised exercise and conservative care come first.
• Symptoms in these patients often reflect early osteoarthritis rather than the meniscal tear itself, so imaging findings should not drive the decision alone.
• Arthroscopy is considered only after a reasonable trial of non-operative management fails, and mechanical symptoms alone are not a strong indication.

Our appraisal: Structured expert consensus (84 surgeons and scientists across 22 countries) built on top of randomised trials that had already shown no benefit of arthroscopy over conservative care, so it is unusually well grounded for a consensus. Its main value is giving clinicians permission to hold off on surgery when the scan shows a tear but the picture is really early osteoarthritis.

An AAOS clinical practice guideline, based on systematic reviews, on the diagnosis and treatment of acute Achilles tendon rupture.

• Most recommendations were graded inconclusive or weak, reflecting limited high-quality evidence at the time.
• Moderate-strength recommendations support early postoperative protective weight-bearing and the use of protective devices that allow early motion.
• Both operative and non-operative pathways can be appropriate, framing the choice as individualised.

Our appraisal: Now dated and built mostly on low-strength recommendations, so it should be read as a floor rather than the last word; its durable message is that early functional rehabilitation matters and that the operative-versus-non-operative decision is a shared one, a position later functional non-operative protocols have reinforced.