Letter in response to BJSM Article: Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline

Dear Editor,

It was with great interest that we read the republished guideline¹ entitled “Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline.” Based on the findings from previous studies, the authors made a strong recommendation against the use of arthroscopy in nearly all patients with degenerative knee disease. They also stated that further research is unlikely to alter this recommendation.

We appreciated the authors’ great efforts on this clinical guideline. However, we have some comments and concerns regarding their recommendations:

(1) Arthroscopic debridement is not the only arthroscopic procedure for degenerative knee disease. Traditionally, arthroscopic procedures for knee osteoarthritis include joint lavage, washout of intra-articular debris and/or partial meniscectomy,¹ and the current literatures did not support the use of these procedures for degenerative knee diseases.^1,2 We agree that “arthroscopic debridement” may be ineffective for knee osteoarthritis; however, we should not state that “arthroscopy” is of no value for patients with degenerative knee disease. Actually, some novel arthroscopic techniques have been proposed, and they seemed to provide potential benefits for knee osteoarthritis. Lyu et al proposed a novel technique, arthroscopic cartilage regeneration facilitating procedure (ACRFP), for management of knee osteoarthritis.³ This procedure includes arthroscopic medial capsule release, percutaneous lateral capsule release and conventional debridement.³ They reported that about 85% of patients were satisfactory with the procedure, but less satisfactory was found in patients with grade IV knee osteoarthritis (59%)³; besides, the Knee Society score (KSS) and knee injury and osteoarthritis outcome score (KOOS) improved significantly.³ Additionally, Lyu et al even reported the reversal of the degeneration process from radiographic evaluation. Yang reported an arthroscopic “L” medial release (ALMR) procedure for the treatment of medial compartment knee osteoarthritis.⁴ In this comparable study, the results showed that visual analogue scale (VAS) and KSS significantly improved in ALMR group but remained relatively the same in control group during the 2-year follow-up.⁴ Yang also described the evidence of increase of medial joint space in some patients treated with ALMR.

(2) The authors stated that further research is unlikely to alter the recommendation against the use of arthroscopy for degenerative knee disease. However, this statement did not take the potential benefits from previous techniques^3,4 into consideration. We believed that more studies will be needed for evaluating the treatment effects of these novel arthroscopic techniques^3,4 on degenerative knee diseases.

Despite these concerns, the authors made a great contribution on this topic.

Sincerely,

Chih-Kai Hong, M.D.

Wei-Ren Su, M.D., M.Sc.

Please address all correspondence to:

Wei-Ren Su, M.D., M.Sc. Department of Orthopaedic Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan, No.138, Sheng-Li Road, Tainan City, Taiwan 70428. E-mail: suwr@ms28.hinet.net

Competing Interests

None declared

References:

1. Siemieniuk RAC, Harris IA, Agoritsas T, et al Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline Br J Sports Med 2018;52:313.
2. Brignardello-Petersen R, Guyatt GH, Buchbinder R, et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open 2017;7:e016114.
3. Lyu SR, Hsu CC, Lin CW Arthroscopic cartilage regeneration facilitating procedure for osteoarthritic knee BMC Musculoskelet Disord 2012;13:226.
4. Yang LM Treatment of medial compartment knee osteoarthritis by arthroscopic ‘L’ medial release procedure Int Orthop 2017;41:2025-2035