The American Academy of Orthopaedic Surgeons (AAOS), which represents more than 38,000 orthopaedists, this week issued its list of “Five Things Physicians and Patients Should Question.” The AAOS’ list is the most recent addition to the Choosing Wisely campaign, a joint venture of the American Board of Internal Medicine (ABIM) Foundation and Consumer Reports.
More than 50 medical specialty societies, including the American College of Rheumatology (ACR), have joined the campaign, which seeks to reduce costs and promote thoughtful medical decision-making by highlighting certain tests and treatments that are routinely used but often unnecessary. (ACR released its top five last year.)
Kevin J. Bozic, MD, vice chair of the department of orthopaedic surgery at the University of California, San Francisco, is the AAOS spokesperson for Choosing Wisely. He stresses that the AAOS list of five recommendations – like those of other specialties – are not meant to be proscriptive or take the place of a provider’s clinical judgment. Instead, they are intended to spark discussions between patients and physicians about the need for certain procedures with the ultimate goal of improving the quality, effectiveness and cost of care.
The Choosing Wisely list was compiled by the AAOS Board of Directors, who spent months reviewing medical literature and considering contraindicated practices before selecting these five:
1. Avoid performing routine postoperative deep vein thrombosis ultrasonography screening in patients undergoing elective hip or knee arthroplasty.
Deep vein thrombosis (DVT) – a blood clot that forms in the deep veins, mainly in the legs – is a potential complication of knee or hip replacement. Doctors have traditionally used a type of ultrasound called duplex ultrasonography to check for clots after surgery. But the test is expensive and has not been shown to reduce the rate of symptomatic DVT, according to AAOS president Joshua J. Jacobs, MD, chair of the department of orthopaedics at Rush Medical College in Chicago. Instead, the AAOS recommends preventive measures known to be safe and effective, including mechanical compression devices that improve blood flow in the legs, aspirin and other anticoagulant medications and early walking after surgery.
2. Don’t use needle lavage to treat patients with symptomatic osteoarthritis (OA) of the knee for long-term relief.
In needle lavage, a saline solution is injected into the joint to flush away debris. But studies have repeatedly shown that needle lavage does not improve pain, stiffness or function, and, Dr. Bozic says, its use may prevent patients from receiving more effective therapies.
3. Do not use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee.
These popular nutritional supplements remain a source of controversy. Although some people have found them helpful, Dr. Bozic points to “a body of literature demonstrating that they do not provide relief for patients with symptomatic OA or prevent disease progression, which is a common misconception.” And because supplements aren’t regulated by the U.S. Food and Drug Administration (FDA), quality can vary widely. In August, Consumer Reports magazine published results of independent tests of 16 glucosamine-chondroitin products. Seven had less than the stated amount of chondroitin – only 65 percent in one case – and two didn’t dissolve properly. “In our opinion, they [glucosamine and chondroitin] have been grossly oversold,” Dr. Bozic says.
4. Do not use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee.
Shoe supports are often recommended for people with knee OA. The idea is to alter the mechanical alignment of the lower leg and reduce loading in the inner part of the knee (closest to the other knee). But according to Dr. Bozic, several randomized controlled trials have demonstrated that lateral wedge insoles don't have this effect. Still, he says, they are a low-cost option that might have some limited benefit. He adds that the recommendation against their use applies only to OA, not other foot or leg problems.
5. Do not use postoperative splinting of the wrist after carpal tunnel release for long-term relief.
The final recommendation, which doesn’t deal directly with arthritis, advises against the use of splints after carpal tunnel surgery. Although commonly prescribed to reduce pain and swelling and hold the hand in place during healing, splinting has not been shown to provide meaningful improvements in pain or grip strength.
“We are not telling doctors or patients what to do. We don’t want to be paternalistic and tell patients they can’t take glucosamine and chondroitin,” says Dr. Bozic. “There may be cases where some of these measures are appropriate, and we always have to take into account a patient’s particular circumstances. But for routine care, we’re hoping people will question their use. The idea is to empower patients to participate in shared decision-making regarding their health care, and [Choosing Wisely] is a powerful tool to help them do it.”