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Noorduyn JCA, van de Graaf VA, Willigenburg NW, et al. Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial. JAMA Netw Open. 2022 Jul 1;5(7):e2220394. doi: 10.1001/jamanetworkopen.2022.20394. (Original study)
Abstract

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.

Ratings
Discipline Area Score
Surgery - Orthopaedics 6 / 7
Family Medicine (FM)/General Practice (GP) 6 / 7
General Internal Medicine-Primary Care(US) 6 / 7
Physical Medicine and Rehabilitation 6 / 7
Comments from MORE raters

General Internal Medicine-Primary Care(US) rater

This study evaluated 321 patients with symptomatic knee arthritis. 1/2 were treated with PT and 1/2 with meniscectomy. 278 were followed for 5 years and the symptoms were essentially the same in both groups as measured by a standard questionnaire. The x-rays similarly showed a similar degree of progression in the two groups. Therefore, PT is a better way to treat degenerative meniscal knee disease.

Physical Medicine and Rehabilitation rater

As the authors mention in the Abstract, "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". In this noninferiority, multicenter randomized clinical trial conducted in the orthopedic departments of 9 hospitals in the Netherlands, the authors' conclusions were that that exercise-based physical therapy was not inferior to arthroscopic partial meniscectomy over a period of 5 years for self-reported knee function, and recommended that exercise-based physical therapy be the preferred treatment over surgery for degenerative meniscal tears. This study supports the evidence from the original investigation, "Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears: The ESCAPE Randomized Clinical Trial" (doi:10.1001/jama.2018.13308).

Surgery - Orthopaedics rater

After short-term benefits were disproved (2 years), some proponents of arthroscopy for degenerative meniscus tears have claimed patients will do better in the long-term. This publication provides empirical evidence that this is not the case. The ITT outcomes matched that of the per-protocol analysis and the index therapy (arthroscopy) in ESCAPE was preserved. Furthermore, non-inferiority was established despite absence of blinding. As such, the estimated effects in the arthroscopy arm are likely inflated, although that could be debated. Exercise therapy remains the first-line, evidenced-based strategy for these tears, particularly when true and worrisome mechanical symptoms are absent.

Surgery - Orthopaedics rater

We are operating too much! Physiotherapy is as good.
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