What Role for Chondroplasty in the Knee?

Commentary The role of chondroplasty in the treatment of pain and functional impairment in the knee remains obscure and even controversial. In their study, Bisson et al. attempted to determine if a chondroplasty at the time of arthroscopic meniscectomy affected patient outcome (symptoms, reoperations, and progression of arthritis) at 5 years postoperatively, compared with no chondroplasty. It is important to note that this is a follow-up study of their previously published study of the same patient cohort at 1 year postoperatively1. In both studies, the authors found no important clinical effect of chondroplasty performed at the time of arthroscopic meniscectomy and therefore concluded that chondroplasty is not necessary in this setting. The authors should be commended for undertaking such a notoriously difficult study. The challenges of prospective randomized trials of the treatment of cartilage disease are well recognized, and the authors made substantial attempts to control for patient heterogeneity (i.e., confounding variables). However, this “strength” is also the main weakness of the study, in the context of how readers might incorporate these findings into their own clinical practices. The result of the study, that chondroplasty of a cartilage lesion “encountered” at the time of meniscectomy does not improve patient outcome, should be considered carefully, as the results may not be widely generalizable to many patients with meniscal pathology who might be treated by an orthopaedic surgeon. The authors identified a very specific group of essentially middle-aged patients (mean age, 54 years) with meniscal tears that did not involve the meniscal root, excluding those with radiographic evidence of more advanced osteoarthritis and those with highly unstable chondral lesions (6%) that the authors apparently thought needed to be treated. Thus, as the authors state, the study patients were ideal candidates for arthroscopic partial meniscectomy, and one might infer that the chondral lesions were not a source of symptoms in this cohort. It is a picky point, but the question remains—were these chondral lesions unstable, symptomatic, or incidental? A recent study in JBJS by Farina et al. provocatively demonstrated that traditionally defined meniscal and mechanical knee symptoms are more strongly associated with the extent of cartilage damage than with meniscal pathology2. I think we all still struggle with deciding whether a meniscal tear or cartilage damage (or both) is the source of symptoms in our middle-aged patients and consequently are challenged by how to counsel and treat them. We simply need better information in order to make informed clinical decisions. The authors have done a commendable job at applying scientific principles (in the form of a hypothesis-driven prospective randomized study) to the question of how and when to treat cartilage damage in the knee. It is still not clear what constitutes reasonable first-line treatment for focal cartilage lesions in the knee, whether symptomatic or not. Can we relieve symptoms? Can we reduce the need for additional surgery? Can we change the natural history? This study suggests the answer is “no,” at least for some patients. I think that this study is an important contribution to the conversation. Chondroplasty of a cartilage lesion encountered at the time of arthroscopic partial meniscectomy may not help, but, unlike alternatives such as microfracture3, it may not harm either.