To Debride or Not to Debride–That Was the Question

During arthroscopic partial meniscectomy (APM), surgeons often encounter articular cartilage lesions. During the procedure, it is difficult to refrain from debridement, especially in the setting of flaps or fibrillated lesions, due to concern about the potential future development of a loose body, progression of the lesion, or mechanical symptoms. As our understanding and research on indications for APM have evolved, we finally now have high-level evidence surrounding what to do in the setting of an incidental chondral finding. Bisson et al. present their 9-year outcomes from the Chondral Lesions And Meniscus Procedures (ChAMP) multicenter randomized controlled trial. Patients undergoing APM for meniscal pathology were randomized to receive either debridement or no debridement (observation) of concurrent unstable chondral lesions identified intraoperatively. The original trial found no benefit to debriding unstable chondral lesions during APM at a 1-year follow-up and actually showed better short-term pain outcomes in favor of observation. A follow-up study of their 5-year outcomes also showed no benefit to chondral debridement in terms of function, joint space narrowing, pain, or need for subsequent surgery1,2. In this most recent study, the authors collected outcomes on 140 patients (76 in the debridement group and 64 in the no-debridement group) from the original group of 190. One hundred and fifteen of these patients completed patient-reported outcome measures (PROMs), 106 underwent physical assessment, and 109 underwent radiographic assessment. No differences were found between the debridement and no-debridement groups in terms of Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) pain scores. There were also no differences in other PROMs, physical assessment measures, radiographic changes, or subsequent surgery rates (secondary outcome measures). The authors concluded from their 9-year outcome data that surgeons should refrain from debriding unstable chondral lesions incidentally identified during APM. Overall, the strength of this study lies in both the randomized design and long-term follow-up, and it remains the single best study in the literature focusing on the specific question of how to address unstable chondral lesions found during APM. The authors’ finding that debridement had no benefit at 1 year, 5 years, and now 9 years sends a clear message that we can refrain from debriding these lesions when they are encountered intraoperatively. The authors do point out some weaknesses of their study in terms of generalizability—most patients were White, few received Medicaid, and the study excluded patients receiving Workers’ Compensation. Also, 26% of the patients in the initial cohort were lost to follow-up, which may have introduced selection bias. However, the authors addressed this limitation by using the multiple imputation technique for handling missing data, which is methodologically sound. Also, there was no difference between treatment groups in terms of the number of patients lost to follow-up. Another limitation is that the study was designed to compare WOMAC pain scores, the primary outcome, and therefore was likely underpowered to detect a difference in the secondary outcomes. The authors did perform a post-hoc power analysis that revealed that their power to detect a 10-point difference in the WOMAC pain score was 66%. Lastly, patients were only blinded to their intervention for the first year of the study, which may have introduced performance bias at the 9-year follow-up. It is important to point out that the conclusions of this study do not tell us that all chondral pathology encountered during APM can be ignored. Patients with true loose bodies or nearly detached chondral fragments are likely a different population, as flap lesions at “risk for detachment” were excluded. To conclude, the ChAMP trial gives us a definitive answer reinforcing that we can be comfortable with not addressing unstable chondral lesions during APM, an approach that perhaps can even provide benefit. As surgeons, we are trained to act. This study gives us a good reason not to.