EDITOR'S NOTE: The corresponding author was invited to respond to this letter but to date has not done so.
To the Editor:
I congratulate Aaron and co-authors for their endeavour to
establish a scientific rationale for arthroscopic debridement as a
treatment for osteoarthritis (OA) of the knee (1). However, I have a few
questions to ask of the authors.
They included patients in whom “treatment
with oral anti-inflammatory medication had failed”, but we are not informed about their criteria for "failure". Quite often patients have not had a
proper trial of anti-inflammatory medications (NSAID) before presenting to the orthopaedic surgeon. For how long did these patients
take NSAIDS? Were there other reason(s) for this failure?(2) If so, were alternative
medication(s) tried?
It appears from figure 1 that patients had to wait at least six
months after arthroscopic debridement before any substantial improvement in symptoms were noted, and they continued to improve for up to 2.5 years afterwards. It is doubtful that this
time frame of symptomatic improvement can be attributed to the index
procedure. The natural history of osteoarthritis is unpredictable.
Symptoms may progess,remain static, or
even improve temporarily (3). We also do not know how many patients were taking medication or other treatments
in the post operative follow up period.
It can be argued that the eight patients with crystal deposition are
likely to be patients with inflammatory arthropathy and their inclusion
introduces heterogeneity into the study population.
I do not think we can conclude from this study that patients with
mechanical symptoms fare poorly after arthroscopy. The series is not large enough to test this assertion. Sixty-two patients had mechanical symptoms pre-
operatively. We are told that as a whole there was post-operative
improvement in pain but we do not know how many of these patients had
improvement of mechanical symptoms. There were fifty-eight knees with
grade 2 OA and sixty-two patients with mechanical symptoms. We do not know
if this sub-group of grade 2 OA had symptoms primarily attributable to OA
or meniscal tear.
Finally, it is probably premature to suggest that arthroscopic
debridement is the preferred treatment for
patients with minimal OA of the knee. There are various
non-surgical treatment options available that might be equally, if not
more effective at this stage and many of them have passed rigorous
research standards (3,4).
References:
1. Aaron RK, Skolnick AH, Reinert SE, Ciombor DM. Arthroscopic
Débridement for Osteoarthritis of the Knee .J Bone Joint Surg Am. 2006;
88:936-943.
2. Hunter DJ, Felson DT. Osteoarthritis. BMJ 2006; 332: 639-42.
3. Buckwalter JA, Stanish WD, Rosier RN, Schenck RC, Dennis DA,
Coutts RD. The increasing need for nonoperative treatment of patients with
osteoarthritis. Clin Orthop Relat Res 2001; 385: 36-45.
4. Bjordal JM, Lopes-Martins RAB, Bogen B, Johnson MI. Physical
treatments have valuable role in osteoarthritis. BMJ, 2006; 332:853.
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