That's great, Kevin. This is great engagement. I think this meeting has been fantastic, and to see this many people here on a Sunday morning is really great. So, thanks, Kevin and Sabrina, for the invite, and Anna and AOSIS-M. So, as Kevin mentioned, my name is Armando Vidal. I'm at the Seddon Clinic in Vail. My charge today is to discuss the role of arthroscopic debridement. Is there a role in the setting of NeoA, and you'll see a theme throughout these talks as we progress through varying levels of invasiveness. Let me see if my thing is going to progress here. There we go. My disclosures are listed in the Academy website, but really none pertinent to this talk. So there are upwards of 750,000 arthroscopies that are performed in the U.S. on an annual basis to the tune of about $4 billion, and it's been almost 20 years since Moseley's sentinel article, which I think we're all aware of, where he looked at debridement, lavage, and sham surgery in knee osteoarthritis, showing no significant improvement. And shortly after this, the media caught attention as evidenced by this front page of the New York Times, subsequent articles in the New York Times and various other media outlets really discounting the role of arthroscopy in arthritis, and then sometimes discounting the role of arthroscopy, period. We've heard a lot about biologics and really their excellent ability to relieve pain for some of these patients, but we all live in urban areas where there are biologic clinics or cellular treatment clinics that will, you know, report that they can cure cancer and diabetes and, you know, retinal detachment, let alone arthritis, ACL injury, meniscus pathology, with their biologic treatments, to the point now that the media has taken these to say maybe our knee arthroscopy doesn't work in any indication. So my goal today is to discuss what the literature really shows and where I think there is a role for arthroscopy, especially in that mild to moderate younger patient with OA. So let's do a deeper dive into some of these studies. So this is a Sentinel article which put it on the map. So this is Mosley's paper. This is published in New England Journal of Medicine. Several of these papers really appeared in JAMA or New England Journal of Medicine and not necessarily in orthopedic journals. This is 180 patients with knee OA randomized to debridement, lavage, or placebo surgery, which is nearly impossible to do in an orthopedic trial. Now the challenge is this was a VA population, predominantly male population, very old, just under 75, showing no difference in outcome at any time point. So despite this being a very well done study with a SHAM control, it failed to get a lot of support specifically because there were questions about methodology, patient selection, and generalizability to our patients that we treat on a daily basis. Is this population the same as my, you know, a 25-year-old offensive lineman in the NFL with mild OA and a meniscal tear? And this is, so there were several editorials that came out shortly after that paper, and I think this is still emblematic of the discussion that we have today almost 20 years later. And this is, you know, to cast doubt on all arthroscopic surgery for OA with the implication that it's worthless does a disservice to the increasing number of people in our population who have early stages of OA and might deprive them of this treatment. And again, just by virtue of the fact that we're having this discussion at our national meeting, I would say that this is still a pertinent comment as it pertains to OA of the knee. So as a result, this came from Sandy Kirkley and the group out of Canada. They tried to develop a study that was also well controlled but more generalizable to the population. They looked at a single center prospect of randomized control trial where patients were randomized to optimize PT and medical treatment versus scope with optimized PT and medical treatment showing really no benefit to knee arthroscopy. Now if you do a deeper dive into this, I think it became very clear from these very well performed and well controlled studies that knee osteoarthritis is not an indication for knee arthroscopy, but I think it also showed that knee osteoarthritis is not a contraindication to knee arthroscopy, and they specifically excluded patients such as this with bucket handle meniscus tears because I think we would all agree that if a patient comes in with mild OA and a locked knee with a bucket handle, that's a patient that requires surgical intervention. So it's important to interpret these studies in the context of what they really showed. So then the question becomes, what do you do with patients like this? This is a patient of mine. This is a 73-year-old gentleman. He's clearly arthritic. He has very well compensated knee OA. He has an excellent envelope of function, but he gets frank mechanical events from this enormous osteous loose body. I think all of us in this room would agree that this is a patient who would benefit from arthroscopic intervention and is not ready for a total knee arthroplasty. How about meniscal pathology in the setting of knee OA or mechanical symptoms? Well, there have been several studies since. So these Sentinel articles that we just discussed, these landmark articles, clearly showed us a knee OA should not be your indication to intervene arthroscopically, but they specifically did not address meniscal pathology, which I would argue is probably the primary indication that any of us would consider arthroscopic intervention in an OA knee. So there have been several studies looking at that specifically. Just in the interest of time so Kevin doesn't throw me off the stage, I'm going to focus on the METEOR trial, which is probably the best of all these trials, the most often quoted. This is from 2013, also in the New England Journal of Medicine. It was a seven center prospective randomized trial of a younger cohort, so patients 45 or over with mild to moderate OA, and Kevin Wilk discussed this in his talk as well, 351 patients randomized to arthroscopic partial meniscectomy or physical therapy with similar WOMAC and CUS scores. You could use this as an argument to say we should never scope an osteoarthritic knee, but if you do a deeper dive, 30% of their patients in the PT group crossed over into the meniscectomy group, and when you look at that group as a whole, or even as individuals, that 30% had zero improvement with physical therapy, and when they were then scoped, they assumed a similar curve to the patients that were scoped from the beginning. So the bottom line is, for us as clinicians, this is challenging, right? We know that meniscal pathology often exists in the setting of OA and is often asymptomatic. We also know that there's probably a subset of patients, and it's hard for us to tell, right? Is it the meniscus tear? Is it the OA? Is it both that's creating pain? So the challenge on us is to try to identify the patients who the meniscus is the source of pain, and this may be an intervention that can benefit them. So in summary, arthroscopy with lavage or debridement, just going in and scoping for OA cannot be recommended for treatment of osteoarthritis of the knee. I would say that there's a general consensus that OA is not an indication for knee arthroscopy, but I would counter that OA is not a contraindication to knee arthroscopy in patients who are appropriately selected. The challenge for us is to continue to define who's an appropriately indicated patient, one so that we can continue to provide this service for our patient, but two so that we can engender support from our third-party payers and our societies to ensure that we still have this treatment modality available to our patients, because clearly there's a subset of patients, that loose body patient, meniscal patients who fail conservative measures and who you feel the meniscus is their primary source of pain who may still benefit from arthroscopy, and I feel that the literature, even these prospective randomized trials bears that out.

Armando Vidal

Seddon Clinic

arthroscopic debridement

knee osteoarthritis

patient selection