July 21, 2022
JAMA Network Open
TAKE-HOME MESSAGE
This 5-year follow-up of the ESCAPE trial examined the long-term (3–5 years) effects of arthroscopic partial meniscectomy versus exercise-based physical therapy (PT) in patients with degenerative meniscal tears. The authors assessed patient-reported knee function and the progression of knee osteoarthritis using radiographs for more than 5 years and found that PT was not inferior to surgical intervention in terms of both measures, with a between-group difference of only 3.5 points (P < .001).
PT is not inferior to arthroscopic partial meniscectomy in patients with degenerative meniscal tears and should be considered the first-line treatment for these patients.
– Alexandra M. Ninneman, MD
Written by Chill C. Yee MD
This study evaluated the effect of physical therapy versus knee arthroscopy in patients with degenerative meniscus tears. This was a multicenter randomized clinical trial involving 321 patients conducted over a 5-year span. The primary endpoints were patient-reported knee function and knee arthritis progression on x-ray. The goal of the study was to demonstrate noninferiority of physical therapy versus knee arthroscopy. The researchers noted that physical therapy and knee arthroscopy yielded similar outcomes.
I have found that treatment discussion for degenerative meniscus tears may be a challenging conversation. The instinct of patients is to lean toward knee surgery in the setting of meniscus tears. However, it is worthwhile to take time to explain the difference in outcomes and risks for degenerative meniscus tear treatments. In my office, I review that surgery is not a risk-free proposition, necessitating commitments for postoperative physical therapy treatments, and has additive significant cost incurred by both patients and healthcare institutions. Alternatively, physical therapy is risk-free, with improved cost savings, and can yield similar or better outcomes in some studies. I find that, once these topics are discussed, most patients tend to choose a nonsurgical management plan for degenerative meniscus tears.
Abstract
This abstract is available on the publisher’s site.
IMPORTANCE
There is a paucity of high-quality evidence about the long-term effects (ie, 3-5 years and beyond) of arthroscopic partial meniscectomy vs exercise-based physical therapy for patients with degenerative meniscal tears.
OBJECTIVES
To compare the 5-year effectiveness of arthroscopic partial meniscectomy and exercise-based physical therapy on patient-reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscal tear.
DESIGN, SETTING, AND PARTICIPANTS
A noninferiority, multicenter randomized clinical trial was conducted in the orthopedic departments of 9 hospitals in the Netherlands. A total of 321 patients aged 45 to 70 years with a degenerative meniscal tear participated. Data collection took place between July 12, 2013, and December 4, 2020.
INTERVENTIONS
Patients were randomly allocated to arthroscopic partial meniscectomy or 16 sessions of exercise-based physical therapy.
MAIN OUTCOMES AND MEASURES
The primary outcome was patient-reported knee function (International Knee Documentation Committee Subjective Knee Form (range, 0 [worst] to 100 [best]) during 5 years of follow-up based on the intention-to-treat principle, with a noninferiority threshold of 11 points. The secondary outcome was progression in knee osteoarthritis shown on radiographic images in both treatment groups.
RESULTS
Of 321 patients (mean [SD] age, 58 [6.6] years; 161 women [50.2%]), 278 patients (87.1%) completed the 5-year follow-up with a mean follow-up time of 61.8 months (range, 58.8-69.5 months). From baseline to 5-year follow-up, the mean (SD) improvement was 29.6 (18.7) points in the surgery group and 25.1 (17.8) points in the physical therapy group. The crude between-group difference was 3.5 points (95% CI, 0.7-6.3 points; P < .001 for noninferiority). The 95% CI did not exceed the noninferiority threshold of 11 points. Comparable rates of progression of radiographic-demonstrated knee osteoarthritis were noted between both treatments.
CONCLUSIONS AND RELEVANCE
In this noninferiority randomized clinical trial after 5 years, exercise-based physical therapy remained noninferior to arthroscopic partial meniscectomy for patient-reported knee function. Physical therapy should therefore be the preferred treatment over surgery for degenerative meniscal tears. These results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT01850719.