I’ll also reference Scott Dye—who scoped his own knee—I believe with the help of his brother. Upon touching different parts of the knee with minimal anesthesia, he found that the soft tissues surrounding the knee were some of the most painful areas. Granted, he did not have an exposed cartilage defect that exposes bone but I’m sure that would be painful as well. However, this does highlight the importance of that soft tissue envelope.
Work by Eric Strauss and others looked at cytokine levels and correlation with functional and pain scales after arthroscopy. He found that IL-6, an inflammatory cytokine, was significantly correlated with pain, with patients in greater pain having higher concentrations of IL-6 within the joint.
I think that if we’re not addressing the synovium and the synovial lining then we are potentially missing part of the picture in these patients.
When we look at the presence of a subchondral bone marrow signal with a cartilage procedure, even though I wouldn’t recommend it for this patient, it’s essentially equivocal.
My argument, Peter, is that there are studies showing that bone marrow lesions correlate with OA-associated pain. While this is certainly part of the story, those studies don’t control for these other factors. They look at the amount of arthritis that’s present, as well as the MR findings, but it may be that those cytokine levels may preempt and actually cause more symptoms for the patients.
We have at least three or four pain generators. In this case, Peter, it is not the bone. It could be the cartilage, it could be the meniscus, and it could be also the synovium or the lining of the joint. I think we have to be careful not to hyper focus on this as the pain generator and not rush to squirt something into the “bone marrow edema.”
Where does the pain start and where does it end? In order to thoughtfully address these questions, we must take into consideration each of the things I have mentioned today. We don’t need to treat just the bone marrow edema. You need to do an HTO. We need to treat the source and I do think that for most of these patients, it starts within the joint and expands outwards. Peter, you’re just wrong.
Thank you very much.
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