Editorial: Getting Evidence Into Practice – or Not: The Case of Viscosupplementation

摘要: N ot news in 2012: ‘‘Viscosupplementation Largely Ineffective’’ [26]. News 2015 and beyond: Market Value to Exceed $2.6 Billion by 2021, says GlobalData’’ [5]. We should be able say three things about any treatment we use: It is effective, it safe, worth the cost. Unfortunately, cannot always achieve this standard orthopaedic surgery, just as elsewhere medicine. Some conditions surgeons treat are too rare for us accumulate solid data how they behave, some procedures too-uncommonly indicated gather high-quality evidence their efficacies. In addition, interventions used looked promising early on, but later fell from favor better research found them less-effective than initially imagined, or even unsafe. Thermal capsullorhaphy [12], certain arthroplasty bearing-surface ‘‘improvements’’ old [23] new [10], use of bone morphogenic protein spinal fusions [6] all come mind here. Surgeons who follow relegate injectable viscosupplements (hyaluronic acid products) list abandoned treatments. Several comprehensive analyses agree that either minimally effective ineffective [9, 14, 20]. They probably though carries risk [20]. To degree not 20], hard make a case value [21]. Yet despite going only one on efficacy-safety-value scorecard, market continues grow [3, 5]. I know there many proponents these treatments community; however, observations viscosupplementation’s inefficacy mine alone. Well-done reviews meta-analyses recommending against have appeared The New England Journal Medicine [7] Annals Internal [20]; Osteoarthritis Research Society International’s (OARSI) guidelines non-surgical management knee osteoarthritis listed viscosupplementation among ‘‘uncertain appropriateness,’’ alongside avocado soybean unsaponfiables, chondroitin, diacerein, glucosamine, rosehip, transcutaneous electrical nerve stimulation, ultrasound [14]. American Academy Orthopaedic released clinical practice guideline 2013 based an analysis best-available research, which concluded, ‘‘We recommend using hyaluronic patients with symptomatic knee’’ [9]. rated recommendation ‘‘strong,’’ meaning was supporting evidence; rating following implication: ‘‘Practitioners Strong [emphasis theirs] unless clear compelling rationale alternative approach present.’’ Editorial Published online: 16 November Association Bone Joint Surgeons1