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A ccording to the 13th law in the novel The House of God [15], excellence in medical care delivery requires doing ‘‘as much nothing as possible.’’ That adage was offered tongue-in-cheek, of course, but it contains a large kernel of truth: It is easy to overdo things, and too much medicine can make us sicker and poorer [3]. One area where we are not doing enough nothing as possible is moderate knee arthritis. For instance, despite the evidence showing that the benefits of hyaluronic acid (HA) injections are ‘‘small and of questionable clinical importance’’ [7], physicians are injecting oceans of this stuff into arthritic knees. At present, more than USD 1.75 billion is currently spent on HA injections. Worse, the market is expected to grow by more than 50% in the next 4 years [10]. It is not like we don’t know the truth. A meta-analysis [11] of 89 studies—cited more than 300 times according to PubMed—concluded HA injections are ‘‘associated with a small and clinically irrelevant benefit and an increased risk for serious adverse events’’. As such, the American Academy Orthopedic Surgeons issued a Clinical Practice Guideline [8] strongly advising against HA injections. A commentary in American Family Physician stated it plainly too: ‘‘Hyaluronic acid [is] ineffective for knee osteoarthritis’’ [12]. Granted, it is ‘‘difficult to get a man to understand something, when his salary depends on his not understanding it’’ as the writer Upton Sinclair once said [13]. But I think physicians’ failure to absorb the message goes beyond the (relatively small) fees earned by pushing HA. Rather, the growing use of HA rests partially on the presence in many physicians of two personality traits, both purposefully cultivated by medical admissions committees: Namely, a propensity for empathy and a propensity for action. Without a doubt, empathy and action usually are worthwhile in medicine. Physicians should connect with their patients; and when physicians are called to do something for their patients, physicians should do it (even if the call comes in the middle of the night). Yet the interaction between these two usually good traits might impede a physician from speaking honestly and saying, ‘‘I am sorry, but I have nothing to offer you.’’ Given the lack of effective treatments for moderate arthritis and the pressure for empathetic action, it’s no surprise that so much HA, an expensive medicine that offers clinically irrelevant benefits, has made its way from syringe to synovium. A note from the Editor-in-Chief: We are pleased to present to readers of Clinical Orthopaedics and Related Research the next ‘‘Not the Last Word.’’ The goal of this column is to explore timely and controversial issues that affect how orthopaedic surgery is taught, learned, and practiced. We welcome reader feedback on all of our columns and articles; please send your comments to eic@clinorthop.org. The author certifies that neither he, nor any members of his immediate family, have any commercial associations (such as consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of Clinical Orthopaedics and Related Research or The Association of Bone and Joint Surgeons.

Not the Last Word: Viscosupplementation, Opioid Overuse, and the Excesses of Empathy