We appreciate and respect the comments by David E. Rojer, MD, on the AAOS clinical practice guideline (CPG) “The Treatment of Osteoarthritis (OA) of the Knee” (“Setting AAOS Now Straight: CPG on OA Knee Disappoints,” AAOS Now, September 2013), and we understand his concerns regarding its use.
A CPG is not a set of rules or protocols and is not intended to be followed in a “cookbook” fashion. Rather, it is a synthesis and synopsis of the best available clinical studies published in peer-reviewed journals or formats. The concept is to systematically (with a protocol) review those thousands of journal articles that Dr. Rojer refers to so that he need not have to do it himself. But, evidence alone does not supplant a physician’s clinical experience or the patient’s values and preferences.
We disagree that the only options are nonsteroidal anti-inflammatory drugs (NSAIDs) or surgery. The CPG supports the use of weight loss, exercise, NSAIDs, acetaminophen, and corticosteroid injections for the conservative management of patients with knee OA. Although several surgical alternatives (including knee arthroscopy for patients with mechanical symptoms or findings and osteotomy) are also supported, the indications for those procedures will be defined in the upcoming appropriate use criteria for this CPG.
As for viscosupplementation, many practicing orthopaedic surgeons report patient findings similar to those Dr. Rojer described. However, the difference in pain scores reported in the literature between patients receiving intra-articular hyaluronic acid injections and those receiving placebo injections is 0.3 on a 10-point visual analog scale and is consistent across systematic reviews. Clinically significant improvement studies in this patient population reveal that a difference of at least 0.5 out of 10 is important to patients.
Lastly and importantly, although the CPG recommends against viscosupplementation based on current best evidence, this recommendation does not prohibit orthopaedic surgeons from using it when clinical experience and a well-informed patient agree to its use.
David Jevsevar, MD, MBA
St. George, Utah
Editor’s note: Dr. Jevsevar chairs the AAOS Evidence Based Quality and Value Committee.
The article on exertional rhabdomyolysis (“Tackling Rhabdomyolysis in College Football Players,” AAOS Now, September 2013) deserves several comments. The basic principles of scientific weight training were described by Harvard orthopaedist Thomas L. DeLorme, MD, in the late 1940s and put to use in the treatment of wounded veterans and children with poliomyelitis. The use of load application is an important intervention for human health, but is virtually ignored by the field of orthopaedics.
Injury and accidents are occurring at an increasing frequency in training rooms and gymnasiums around the country, resulting from a gross deviation from the principles developed by Dr. DeLorme. We as orthopaedic surgeons are complicit in this epidemic because we neglect teaching the principles of load application to the musculoskeletal system as part of orthopaedic training, leaving it to personal trainers, fitness gurus, and strength coaches.
Dr. Amendola should be commended for bringing this situation to light. But even this article demonstrates the misunderstandings held by well-trained orthopaedic surgeons. The workout that injured those players used 50 percent of their one-repetition maximum, applied for 100 repetitions. This is an unnecessary, excessive number of repetitions that does not represent an eccentric muscle lengthening.
Orthopaedic medicine should reexamine the study of load application for the treatment of patients with musculoskeletal disease and incorporate these studies into the training and education of orthopaedic surgeons. We should embrace and take ownership of this valuable treatment method and not simply assume our players and patients are being properly advised by nonmedical therapists.
Michael MacMillan, MD
Setting Now Straight
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