Commentary & Perspective
Arthroscopic procedures for the treatment of meniscal injuries in the knee are one of the most commonly performed orthopaedic procedures in the United States. In a recent review of cases submitted for Part II of the American Board of Orthopaedic Surgery certification examination, CPT code 29881 (partial meniscectomy) was the most commonly submitted procedural code for five consecutive years between 1999 to 2003, surpassing the next most frequent procedure by a margin of 2:11.
However, despite the frequency with which this procedure is performed and the relative low morbidity and generally favorable results with which it is associated, poor results are common in patients with preexisting degenerative joint disease2. For providers whose practices are focused largely on the arthroscopic treatment of knee injuries, it is often impossible to determine clinically which patients with mild degenerative joint disease and meniscal pathology will benefit from arthroscopic treatment. Despite evidence-based guidelines to aid in decision-making, the results are not always predictable or durable.
In light of recent level-I evidence data that arthroscopy is not beneficial specifically for the treatment of osteoarthritis of the knee3, studies of this nature are particularly pertinent. The use of arthroscopic procedures to treat mechanical knee symptoms and meniscal abnormalities in patients with mild osteoarthritis has great value to many patients but has been called into question in the medical community. The authors of this paper should be commended for their efforts and their discovery of a novel fibronectin-aggrecan complex that is present in the synovial fluid of patients with symptomatic meniscal tears. This is potentially a first step in discovering the “holy grail” of a clinical marker that can predict a patient’s response to arthroscopic knee surgery.
As the authors point out, there are several limitations to this study that prevent broad application. It remains unclear if patients with painful mild or moderate osteoarthritis without meniscal pathology will demonstrate elevated levels of this fibronectin-aggrecan complex. Additionally, it is unclear at this time if surgical outcomes correlate with the levels of this complex. This clinical correlation will be necessary to determine if this complex can be used for clinical decision-making in an efficient and cost-effective manner.
In summary, this is a very interesting paper that is particularly pertinent at this time. The authors should be commended for their efforts. Their goal of discovering a biomarker that can distinguish knees with symptomatic meniscal tears that are likely to respond to arthroscopic treatment from knees that are unlikely to respond to surgery is extremely valuable to the orthopaedic community. Much work remains before we are at a point that such technology is readily available. However, studies of this nature are a first step toward that important goal.
*Disclosure: The author did not receive any outside funding or grants in support of his research for or preparation of this work. The author, or a member of his immediate family, received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (MTF).
1. Garrett WE Jr, Swiontkowski MF, Weinstein JN, Callaghan J, Rosier RN, Berry DJ, Harrast J, Derosa GP . American Board of Orthopaedic Surgery Practice of the Orthopaedic Surgeon: Part-II, certification examination case mix. J Bone Joint Surg Am. 2006;88:660-7.
2. Ferkel RD, Davis JR, Friedman MJ, Fox JM, Del Pizzo W, Snyder SJ, Berasi CC . Arthroscopic partial medial meniscectomy: an analysis of unsatisfactory results. Arthroscopy. 1985;1:44-52.
3. Moseley JB, O’Malley K, Petersen NJ, Menke TJ, Brody BA, Kuykendall DH, Hollingsworth JC, Ashton CM, Wray NP . A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2002;347:81-8.