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The Incidence of DVT
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LETTERS TO THE EDITOR
describe lavage as “overly stretching the definition of placebo.” In our opinion, the title “Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscus tear” is misleading, and Sihvonen et al. and the New England Journal of Medicine editors are guilty of suboptimal research methods and bias, respectively.2 With regard to the ethics of sham surgery, we admire that you are published experts,3 and acknowledge its use is controversial, but we humbly distinguish sham surgery from the more acceptable form of placebo control in nonsurgical research. Strictly defined, sham is “something that is not what it appears to be and that is meant to trick or deceive people.”4 Although we agree the debate should be open, the word “sham” itself ruffles our feathers as deception. We respectfully challenge the statement that “patients are either being denied surgery that actually works, or are being exposed to unnecessary danger for an intervention that has no value beyond placebo.” This description paints a black and white picture of the gray reality. When proper indications for surgical treatment of meniscus pathology are chosen, partial meniscectomy works.5-7 And until proven otherwise, “sham” does not. James H. Lubowitz, M.D. Editor-in-Chief Matthew T. Provencher, M.D. Assistant Editor-in-Chief Michael J. Rossi, M.D. Deputy Editor Ó 2014 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.08.003
References 1. Rossi MJ, D’Agostino RB Jr, Provencher MT, Lubowitz JH. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Arthroscopy 2014;30:536-537. 2. Lubowitz JH, Provencher MT, Rossi MJ. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Part 2. Arthroscopy 2014;30:654-655. 3. Campbell MK, Entwistle VA, Cuthbertson BH, Skea Z, Sutherland AG, McDonald AM, et al. Developing a placebo controlled trial in surgery: Issues of design, acceptability and feasibility. Trials 2011;12:50. 4. Sham [Def 1]. In Merriam Webster Online. Available at http:// www.merriam-webster.com/dictionary/sham. Accessed 14 August 2014. 5. Lubowitz JH, Poehling GG. Save the meniscus. Arthroscopy 2011;27:301-302. 6. Petty CA, Lubowitz JH. Does arthroscopic partial meniscectomy result in knee osteoarthritis? A systematic review with a minimum of 8 years’ follow-up. Arthroscopy 2011;27:419-424. 7. Lubowitz JH, Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: Knee
arthroscopy and knee anterior cruciate ligament reconstruction. Arthroscopy 2011;27:1317-1322.
The Incidence of DVT To the Editor: I read with interest the article entitled “Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: A retrospective study with routinely applied venography” by Sun et al. in the July 2014 issue. I was quite frankly surprised by the high incidence of asymptomatic DVT. Going into the specifics of the “Methods” section, it seems that Sun et al. mentioned that they started mobilization on day 4. If so, it could explain the high incidence of DVT they report. If they had started earlier, it is not obvious from the methodology. My group has published 2 studies in which there was no significant difference in DVT rates when early mobilization was begun,2,3 irrespective of DVT prophylaxis. On the basis of the numbers mentioned in the study by Sun et al.,1 could these numbers be reflective of a racial/ regional variation? Second, have they started using DVT prophylaxis routinely following these observations? Ashish Anand, M.D. Jackson, Mississippi Note: The author reports that he has no conflicts of interest in the authorship and publication of this letter. Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.08.005
References 1. Sun Y, Chen D, Xu Z, et al. Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: A retrospective study with routinely applied venography. Arthroscopy 2014;30: 818-822. 2. Raviraj A, Anand A, Kodikal G, Chandrashekar M, Pai S. A comparison of early and delayed arthroscopically assisted reconstruction of the anterior cruciate ligament using hamstring autograft. J Bone Joint Surg Br 2010;92:521-526. 3. Raviraj A, Anand A, Kodikal G. Incidence of deep vein thrombosis and thromboprophylaxis in patients undergoing arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop 2011;5:450-453.
Authors’ Reply We appreciate the concerns Dr. Anand raised in his letter on our latest study published in the July 2014 issue.
LETTERS TO THE EDITOR
describe lavage as “overly stretching the definition of placebo.” In our opinion, the title “Arthroscopic partial meniscectomy versus sham surgery for a degenerative meniscus tear” is misleading, and Sihvonen et al. and the New England Journal of Medicine editors are guilty of suboptimal research methods and bias, respectively.2 With regard to the ethics of sham surgery, we admire that you are published experts,3 and acknowledge its use is controversial, but we humbly distinguish sham surgery from the more acceptable form of placebo control in nonsurgical research. Strictly defined, sham is “something that is not what it appears to be and that is meant to trick or deceive people.”4 Although we agree the debate should be open, the word “sham” itself ruffles our feathers as deception. We respectfully challenge the statement that “patients are either being denied surgery that actually works, or are being exposed to unnecessary danger for an intervention that has no value beyond placebo.” This description paints a black and white picture of the gray reality. When proper indications for surgical treatment of meniscus pathology are chosen, partial meniscectomy works.5-7 And until proven otherwise, “sham” does not. James H. Lubowitz, M.D. Editor-in-Chief Matthew T. Provencher, M.D. Assistant Editor-in-Chief Michael J. Rossi, M.D. Deputy Editor Ó 2014 by the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.08.003
References 1. Rossi MJ, D’Agostino RB Jr, Provencher MT, Lubowitz JH. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Arthroscopy 2014;30:536-537. 2. Lubowitz JH, Provencher MT, Rossi MJ. Could the New England Journal of Medicine be biased against arthroscopic knee surgery? Part 2. Arthroscopy 2014;30:654-655. 3. Campbell MK, Entwistle VA, Cuthbertson BH, Skea Z, Sutherland AG, McDonald AM, et al. Developing a placebo controlled trial in surgery: Issues of design, acceptability and feasibility. Trials 2011;12:50. 4. Sham [Def 1]. In Merriam Webster Online. Available at http:// www.merriam-webster.com/dictionary/sham. Accessed 14 August 2014. 5. Lubowitz JH, Poehling GG. Save the meniscus. Arthroscopy 2011;27:301-302. 6. Petty CA, Lubowitz JH. Does arthroscopic partial meniscectomy result in knee osteoarthritis? A systematic review with a minimum of 8 years’ follow-up. Arthroscopy 2011;27:419-424. 7. Lubowitz JH, Appleby D. Cost-effectiveness analysis of the most common orthopaedic surgery procedures: Knee
arthroscopy and knee anterior cruciate ligament reconstruction. Arthroscopy 2011;27:1317-1322.
The Incidence of DVT To the Editor: I read with interest the article entitled “Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: A retrospective study with routinely applied venography” by Sun et al. in the July 2014 issue. I was quite frankly surprised by the high incidence of asymptomatic DVT. Going into the specifics of the “Methods” section, it seems that Sun et al. mentioned that they started mobilization on day 4. If so, it could explain the high incidence of DVT they report. If they had started earlier, it is not obvious from the methodology. My group has published 2 studies in which there was no significant difference in DVT rates when early mobilization was begun,2,3 irrespective of DVT prophylaxis. On the basis of the numbers mentioned in the study by Sun et al.,1 could these numbers be reflective of a racial/ regional variation? Second, have they started using DVT prophylaxis routinely following these observations? Ashish Anand, M.D. Jackson, Mississippi Note: The author reports that he has no conflicts of interest in the authorship and publication of this letter. Published by Elsevier Inc. on behalf of the Arthroscopy Association of North America http://dx.doi.org/10.1016/j.arthro.2014.08.005
References 1. Sun Y, Chen D, Xu Z, et al. Incidence of symptomatic and asymptomatic venous thromboembolism after elective knee arthroscopic surgery: A retrospective study with routinely applied venography. Arthroscopy 2014;30: 818-822. 2. Raviraj A, Anand A, Kodikal G, Chandrashekar M, Pai S. A comparison of early and delayed arthroscopically assisted reconstruction of the anterior cruciate ligament using hamstring autograft. J Bone Joint Surg Br 2010;92:521-526. 3. Raviraj A, Anand A, Kodikal G. Incidence of deep vein thrombosis and thromboprophylaxis in patients undergoing arthroscopic anterior cruciate ligament reconstruction. Indian J Orthop 2011;5:450-453.
Authors’ Reply We appreciate the concerns Dr. Anand raised in his letter on our latest study published in the July 2014 issue.