Letters to the Editor - Dec. 8, 2008

Arthroscopic surgery has a role, which is more common than skeptics allow

Regarding "Common osteoarthritis treatments questioned" (Article, Oct. 13): I find the article to be interesting as a summary, but it is really nothing new to the conscientious orthopedic surgeon.

I have been in practice for close to 14 years, and I was always trained that the arthritic knee without mechanical symptoms should not be an arthroscopic candidate. The fact that this information supports the trend to the board-certified conscientious orthopedic surgeon is really almost not news.

What is interesting, however, is the fact that Dr. Martin Englund, as lead author of a New England Journal of Medicine article cited by AMNews, indicates that "surgery has a place but in very few selected cases."

I am not sure whether the doctor is justified in reporting "very few," as many of my elderly patients who have had long-standing osteoarthritis symptoms suddenly become symptomatic for mechanical symptoms in which a meniscus tear is the source of the pain. I am very careful to make sure they have realistic expectations, and that the goals are to remove the mechanical problems and not the arthritic change.

While that is said, there have been procedures that are somewhat effective in some cases. Research should continue in terms of good clinical guidelines as when to proceed, but patients and practitioners need not be inappropriately scared away from the procedure or recommending it.

I also find it interesting that we can send patients for MRIs and find the tears, but only conscientious judgment will help decipher the indicated from the non-indicated patients.

The brain attached to the hands is more valuable than the interpretation attached to the scan. Maybe we should be paying more for the clinical judgment of the practitioner than we are paying the scanner for their scan. (Medical Assistance, Pennsylvania's Medicaid program, for instance, considers my opinion on this matter to be worth about $20.)

--Daniel J. D'Arco, MD, Pottsville, Pa.

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