Hyaluronic Acid, Meniscal Debridement Deemed Worthless in Reviews

Schmajuk G, Bozic KJ, Yazdany J. Research Letter: Using Medicare Data to Understand Low-Value Health Care: The Case of Intra-articular Hyaluronic Acid Injections. JAMA Intern Med. (2014) August 25. doi:10.1001/jamainternmed.2014.3926

Khan M, Evaniew N, Asheesh Bedi A, et al. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ  (2014) August 25. doi: 10.1503/cmaj.140433.

Separate reviews this week revisit the evidence against two procedures commonly used for knee osteoarthritis (KOA): hyaluronic acid (HA) injections and debridement as part of meniscectomy. One of them inquires into generally which physicians where continue to useHA injections for KOA although they have been judged of "low value".

The injections are controversial. The US Food and Drug Administration approved HA injections for severe KOA in 1997. A 2006 Cochrane review supported them, as did older papers and guidelines (always citing a low effect magnitude). But a 2012 meta-analysis in the Annals of Internal Medicine and a 2013 clinical practice guideline from the American Academy of Orthopaedic Surgeons (AAOS) found “strong” evidence against them, describing the injections as “low value.”

The authors of the new assessment of HA injections are the chair of the  oversight group for the AAOS guideline (Dr. Bozik) and two rheumatologists who contributed to the American College of Rheumatology’s Choosing Wiselylist of questionable medical procedures (Drs. Schmajuk and Yazdany). Their letter to JAMA Internal Medicine features a map (visible via the link to the first article title above) that shows where the procedure is in greatest use despite the recommendations against it.

In 2012, they report, Medicare Part B reimbursed 12,761 clinicians for 1,161,924 HA injections for KOA among 423,669 patients. Orthopedic surgeons performed 59% of these injections. Other providers were primary care physicians (11%), physician assistants (10%), and rheumatologists (only 8%). The average cost to Medicare was $179 for the HA and $69 for the injection.

"Rates of HA injections were highest in the New York and DC metropolitan areas, as well as other pockets in the Southern US including south Florida, south Texas, and Arizona," Dr. Schmajuk said in an email.

A separate evidence-based review has examined arthroscopic debridement of meniscal tears in middle-aged patients with mild or no osteoarthritis, and found no evidence of benefit. Previous studies have found no benefit in patients with severe and advanced arthritis.

This reviewers evaluated seven randomized, controlled trials including 805 patients. They dichotomized outcomes into short-term (<6 months) and long-term (up to 2 years).

The review measured patient-based outcomes related to pain, function and post-surgical complications, assessed by converting all results to a Knee Injury and Osteoarthritis Outcome Score that evaluates five domains: pain frequency and severity, symptoms, activities of daily living, sport and recreational activities, and knee-related quality of life.

There was a statistically significant benefit in short-term function, but not a clinically significant benefit, as measured by minimally important difference (MID), the smallest clinical difference that a patient can perceive.

Arthroscopic debridement didn’t show an improvement in pain in those trials that reported visual analogue scores. The trials reported one infection and three serious adverse events in the treatment groups, compared to two adverse events in a physical therapy group.

Five trials of this procedure are currently registered on ClinicalTrials.gov, with four ongoing and one completed but unpublished.