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AbstractKnee osteoarthritis (KOA) represents one of the most costly and clinically ambiguous conditions in modern musculoskeletal care. Intra-articular hyaluronic acid (HA) viscosupplementation occupy a contested position between conservative therapy and total knee arthroplasty, simultaneously supported by widespread clinical use and challenged by guideline skepticism and payer resistance. This article argues that the controversy surrounding viscosupplementation is not fundamentally pharmacologic, but evidentiary. By shifting from retrospective, inferential data to prospectively captured, schema-driven real-world evidence (RWE), providers can generate deterministic “ground truth” capable of resolving long-standing disputes over efficacy, value, and appropriate patient selection. We examine how imaging-verified delivery, longitudinal outcomes, and synthetic control arms can transform viscosupplementation from a commoditized procedure into a verifiable, value-based intervention.The Viscosupplementation ParadoxThe global viscosupplementation market is substantial and growing, driven by demographic aging and the rising prevalence of osteoarthritis. Estimates place the market between approximately $1.6 and $4.7 billion annually, with projected compound annual growth rates near 8–9% through the early 2030s. Despite this scale, viscosupplementation remains persistently controversial.Clinical guidelines illustrate this tension. The American Academy of Orthopaedic Surgeons (AAOS) has historically recommended against routine use of HA injections for knee osteoarthritis, citing modest average improvements over placebo in randomized controlled trials (RCTs). Although the most recent guidelines softened earlier language, they continue to question whether statistically significant effects translate into clinically meaningful benefit for the average patient. In contrast, rheumatology societies and manypracticing clinicians report consistent benefit in carefully selected patients, particularly earlier in the disease course.This disconnect has real consequences. Payers increasingly impose step-therapy requirements, restrict coverage, or deny reimbursement altogether. Providers face heightened audit risk, while manufacturers struggle to defend formulary placement. Yet none of these actors dispute the underlying biology of HA; rather, they disagree about who benefits, under what conditions, and by how much.The Limits of Conventional EvidenceAt the heart of the controversy lies a structural problem in how evidence is generated. Traditional RCTs in knee osteoarthritis aggregate heterogeneous populations, often including late-stage patients with minimal remaining cartilage — patients unlikely to respond to viscosupplementation. This dilution effect suppresses observed efficacy and masks responder subgroups.Compounding the issue is the unusually large placebo response in osteoarthritis trials. Placebo effects account for up to 60–75% of observed pain reduction in some intra-articular injection studies, obscuring true treatment effects and contributing to late-stage trial failures. When outcomes are subjective and follow-up inconsistent, inferential gaps become unavoidable.Real-world data, as currently captured, does little to solve this problem. Claims data and unstructured electronic medical record (EMR) notes lack confirmation of intra-articular delivery accuracy, disease severity, or standardized outcomes. These “data exhaust” sources require heavy inference and cannot establish causality. As a result, regulators, payers, and guideline bodies are forced to guess at value rather than verify it.Schema-on-Capture and Deterministic Ground TruthA fundamentally different approach is required — one that treats data generation as a clinical act rather than a byproduct of billing. The schema-on-capture model proposes defining the evidentiary architecture before care is delivered. In the context of viscosupplementation, this means prospectively capturing:Verified delivery: Fluoroscopic or image-guided confirmation that HA was delivered intra-articularly, rather than peri-articularly or into the fat pad. Accuracy rates for blind knee injections may be as low as 70–80%, compared with >95% for image-guided techniques, a difference with potential downstream impact on outcomes.Structured disease state: Radiographic severity (e.g., Kellgren–Lawrence grade, joint space width) captured in standardized, machine-readable form.Longitudinal outcomes: Validated patient-reported outcome measures (WOMAC, KOOS-JR) collected at fixed intervals, combined with objective endpoints such as time to total knee arthroplasty.Optional biologic context: Synovial fluid biomarkers, when available, to characterize inflammatory phenotypes associated with response or non-response. By enforcing structure at the moment of care, schema-on-capture eliminates the inference gap. Each record becomes a deterministic unit of evidence rather than a probabilistic data point.Precision, Placebo, and the Synthetic Control ArmOne of the most powerful applications of deterministic RWE is the construction of high-fidelity synthetic control arms. In osteoarthritis drug development, placebo-controlled trials are expensive, slow, and ethically contentious due to high screen-failure rates and strong placebo responses. Pharmaceutical sponsors routinely spend $40,000–$100,000 per patient in late-phase trials.An imaging-verified, longitudinal dataset of patients receiving standard-of-care viscosupplementation can serve as an external comparator, dramatically reducing trial costs while improving interpretability. Unlike conventional registries, such datasets explicitly characterize the “ritual of care” associated with injections — frequency of visits, imaging, clinician interaction — allowing placebo effects to be modeled rather than ignored .This approach aligns with growing regulatory acceptance of real-world evidence and synthetic control methodologies, particularly in areas where traditional trials are impractical or ethically fraught. Importantly, the value of such datasets derives not from scale alone, but from veracity.Economic Implications: From Commodityto AssetHealthcare data is often treated as a commodity, but evidence quality follows a steep valuation gradient. Low-fidelity claims data may command $50–$150 per record, while curated clinical registries reach $500–$1,500 per patient. Deterministic, regulatory-grade longitudinal records — analogous to those that underpinned acquisitions such as Flatiron Health and CorEvitas — can justify valuations exceeding $5,000 per record when used in regulatory, payer, or drug-development contexts.For large KOA provider groups, this reframes the economics of care delivery. Rather than maximizing procedure volume under reimbursement pressure, practices can generate durable data assets that support value-based contracts, post-market surveillance, and licensing to life-science partners. In this model, data quality becomes a clinical and financial imperative.Reframing the Clinical DebateThe long-running dispute over viscosupplementation efficacy has persisted not because the therapy is ineffective, but because the evidence infrastructure has been inadequate. Average effects derived from heterogeneous populations and unverified delivery cannot resolve questions of precision medicine.Deterministic RWE offers a path forward. By identifying responder phenotypes, verifying technical success, and anchoring outcomes in longitudinal reality, clinicians can move the discussion from ideology to proof. For payers and regulators, this enables rational coverage decisions based on measurable cost avoidance, such as delayed arthroplasty. For patients, it offers a clearer answer to asimple question: Will this work for someone like me?ConclusionKnee osteoarthritis sits at the intersection of clinical uncertainty, economic pressure, and regulatory scrutiny. Viscosupplementation has become a proxy battle for deeper failures in how healthcare value is measured. The solution is not another meta-analysis of imperfect trials, but a structural redesign of evidence generation itself.Schema-on-capture, imaging-verified delivery, and deterministic real-world datasets allow providers to become architects of truth rather than subjects of inference. In doing so, they can transform viscosupplementation from a contested procedure into a verifiable, precision-guided intervention — and, in the process, redefine their role in the evidence economy.‍References RegenMed, Circle Datasets for the Viscosupplements Market with a Focus on Knee Osteoarthritis, December 2025. American Academy of Orthopaedic Surgeons. Management of Osteoarthritis of the Knee (Non-Arthroplasty): Clinical Practice Guideline, 2021. Borst et al. Placebo Effect Sizes in Clinical Trials of Knee Osteoarthritis Using Intra-Articular Injections. Arthritis Care & Research, 2025. Roche. Roche to Acquire Flatiron Health to Accelerate Industry-Wide Use of Real-World Data, 2018. Thermo Fisher Scientific. Thermo Fisher Scientific Acquires CorEvitas for $912.5M, 2023.‍

Why most healthcare AI breaks under real-world conditions — and how verifiable data makes it durable. From Accuracy to Fragility Healthcare AI excels in benchmarks and struggles in practice. An algorithm may post a 94 percent F1-score in validation and still misfire when exposed to the variability of actual care. Small shifts in patient demographics, documentation style, or instrumentation can degrade performance overnight. This brittleness is not a model flaw; it is a data inheritance problem. AI learns whatever instability exists in its training source — and amplifies it. When the foundation is incomplete, intelligence becomes fragile. The Hidden Instability in Healthcare Data Clinical data is inherently dynamic: patients move across systems, therapies evolve, and coding standards shift. Yet most training datasets capture a single snapshot in time — an incomplete view that cannot sustain learning across change. This leads to three predictable weaknesses: Temporal drift: models trained on past cohorts fail on present ones. Context loss: missing longitudinal context creates misleading correlations. Structural noise: inconsistent coding and missing metadata degrade signal quality. In other words, today’s AI is only as stable as yesterday’s documentation. Verification as Structural Reinforcement Circle resolves fragility by embedding verification into the data’s life cycle. Every record is created under an Observational Protocol that enforces standardized capture, continuous lineage tracking, and cryptographic validation. This transforms raw data into ground truth — information with structural integrity: Each variable’s origin and update history are recorded. Quality metrics and validation status travel with the record. Time, context, and consent remain verifiable across every reuse. The result is a learning substrate that can withstand change because its truth is self-documenting. Resilience Through Continuity Resilient intelligence requires continuity, not just volume. When AI models train on Circle datasets, they inherit longitudinal consistency: patient trajectories, treatment histories, and outcomes are all linked through verifiable timelines. This continuity stabilizes learning curves and reduces model drift. Algorithms retrain faster, recalibrate automatically, and maintain performance as clinical patterns evolve. For clinicians, that means reliability; for regulators, traceability; for investors, predictable durability. Operational and Economic ImpactFragile AI increases downstream cost: more manual oversight, more false positives, more wasted validation cycles. Resilient AI built on verified data does the opposite — it compounds efficiency. Hospitals spend less time auditing; payers process fewer disputes; researchers reuse datasets confidently across studies. Each proof-ready dataset becomes a reusable asset that strengthens with time — turning verification from a defensive measure into a productivity engine. Strategic Outcome The failure of fragile intelligence is not a cautionary tale — it’s an engineering lesson. Healthcare AI will mature when it stops optimizing for accuracy and starts designing for durability. Circle’s verifiable data architecture gives the industry that foundation: a continuous, self-reinforcing evidence base where learning models evolve safely with reality rather than apart from it. In a market now defined by reproducibility and accountability, resilience — not novelty — is the new frontier of intelligence. Key Takeaways Get involved or learn more — contact us today!If you are interested in contributing to this important initiative or learning more about how you can be involved, please contact us.

As 2026 approaches, orthopedic surgery faces what Dr. Ronald Gardner describes as a "sustainability test" driven by rising labor costs, "quiet" reimbursement cuts to RVUs, and an ever-mounting administrative burden.At RegenMed, we believe the only way to pass this test is to bridge the "Inference Gap" — moving away from the probabilistic guesses of billing-code data and toward Deterministic Evidence captured directly by the treating physician.Here is how we are partnering with orthopedic leaders to reclaim the evidence-based "Practice of Medicine":1. Stop the Revenue ErosionWhile traditional production revenue cycles are down per unit of work, RegenMed’s Dividend Model transforms clinical documentation into a high-margin asset. By minting "Ground Truth" at the point of care, we repatriate 75–85% of net data license fees back to the clinical source, creating a sustainable research and revenue engine.2. Reclaim Scientific SovereigntyDr. Gardner notes that research has historically not focused on identifying when fewer interventions can deliver equivalent outcomes. RegenMed provides the infrastructure for Scientific Sovereignty, allowing surgeons to own their data and define the standards of their specialty — proving when conservative care is as effective as surgery and when high-cost procedures are clinically justified.3. Treat the Patient, Not the X-RayCustomizing care to a patient’s life — not just their imaging — requires having multiple, validated treatment options available. Our Circle Datasets provide the high-fidelity evidence needed to validate individualized care pathways, ensuring that the "value" in value-based care is determined by actual clinical results, not administrative algorithms.Orthopedic innovation is only sustainable when clinicians are the primary architects of the evidence they create. Join the Network for Clinical Veracity. Launch your private Circle today and turn your clinical documentation into a scientific legacy.‍

The PremiseScience was once governed by disciplined inquiry and collective verification. Its slow, cumulative rhythm ensured that discoveries matured through scrutiny. In the modern research economy, that rhythm has been replaced by velocity. Today, scientific progress is defined by publication count rather than intellectual contribution. Publishability — the capacity to generate a result fast enough, fashionable enough, and fundable enough — has become the operative currency of success.The Distortion Under this regime, novelty eclipses reliability. A finding that is intriguing but unstable will outcompete a replication that is dull but true. Incentives reward the easily cited over the carefully tested. Peer review, once a mechanism for quality control, functions largely as a formality — a procedural endorsement of productivity. Journals compete not for accuracy but for attention, chasing “impact factors” that often correlate with controversy, not validity. The entire system has inverted: signaling replaces substance. The Consequence The resulting distortion corrodes the epistemic fabric of science. Research becomes a form of theater — designed for visibility rather than veracity. Young scientists internalize a survival logic: select questions that yield publishable noise, not durable knowledge. Institutions respond with metrics and dashboards that quantify reputation without measuring truth. The consequence is a vast accumulation of papers that cannot replicate, policies that mislead, and technologies that rest on statistical mirages. The Way Forward Repair begins with incentive inversion. Journals must reward correction over discovery, transparency over novelty. Funders should prioritize reproducibility studies and open datasets as legitimate endpoints. Institutions must recalibrate tenure metrics to reflect truth maintenance rather than paper velocity. Above all, science must remember its moral identity: a covenant with uncertainty, not a contest of output. The tyranny of the publishable ends only when humility is restored as the highest form of rigor. References RegenMed (2025). Genuine Medical Research Has Lost Its Way. White Paper, November 2025. Ioannidis, J. P. A. (2005). Why Most Published Research Findings Are False. PLoS Medicine, 2(8). Brembs, B. (2018). Prestige Journals and the Reproducibility Crisis. Frontiers in Human Neuroscience, 12, 37. Smaldino, P. E., & McElreath, R. (2016). The Natural Selection of Bad Science. Royal Society Open Science, 3(9). Sarewitz, D. (2016). The Pressure to Publish Pushes Down Quality. Nature, 533(7602), 147. Horton, R. (2015). Offline: What Is Medicine’s 5 Sigma? The Lancet, 385(9976), 1380. ‍

On December 15 the FDA issued a news release highly supportive of the clinical, regulatory, and financial value of RegenMed Circle Datasets. Circle Datasets need no IRB or other outside validation beyond this clearly stated FDA policy. They deliver exactly what the FDA is looking for: fit-for-purpose structure, correlated outcomes, statistical significance, and data provenance in the context of practice-of-medicine hypotheses and corresponding data. To this are added clear ownership rights and compliant monetization opportunities for contributing physicians.