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Randomized Controlled Trial
. 2022 Jul 1;5(7):e2220394.
doi: 10.1001/jamanetworkopen.2022.20394.

Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial

Julia C A Noorduyn  1   2 , Victor A van de Graaf  1   3 , Nienke W Willigenburg  1 , Gwendolyne G M Scholten-Peeters  2 , Esther J Kret  1 , Rogier A van Dijk  4 , Rachelle Buchbinder  5 , Gillian A Hawker  6 , Michel W Coppieters  2   7 , Rudolf W Poolman  1   8 ; ESCAPE Research Group
Affiliations
Randomized Controlled Trial

Effect of Physical Therapy vs Arthroscopic Partial Meniscectomy in People With Degenerative Meniscal Tears: Five-Year Follow-up of the ESCAPE Randomized Clinical Trial

Julia C A Noorduyn et al. JAMA Netw Open. .

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Ms Noorduyn reported receiving a health care efficiency research grant from The Netherlands Organisation for Health Research and Development (ZonMw); grants from the Achmea Healthcare Foundation; grants from the Foundation of Medical Research OLVG, Amsterdam; and from the OLVG science committee and the Dutch Arthritis Society (ReumaNederland) outside the submitted work. Dr van de Graaf reported receiving grants from ZonMw, and grants from the Foundation of Medical Research OLVG, Amsterdam, the Netherlands, during the conduct of the study. Dr Willigenburg reported receiving grants from OLVG, ReumaNederland; grants from OLVG ZonMw; grants from OLVG; Joint Research Zilverenkruis Health Insurance (Achmea Healthcare Foundation); and grants from OLVG, Joint Research Foundation of Medical Research of the OLVG during the conduct of the study. Ms Kret reported receiving grants from OLVG Joint Research Dutch Arthritis Society (ReumaNederland), ZonMw, grants from OLVG Joint Research Zilverenkruis Health Insurance (Achmea), and grants from OLVG Joint Research Foundation of Medical Research of the OLVG, Amsterdam, during the conduct of the study. Dr Poolman reported receiving grants from ZonMw, Achmea, and ReumaNederland during the conduct of the study; and grants from Link, Lima, and the Dutch Orthopaedic Association outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Flow of Patients
aThe number of patients screened for eligibility was not available. The flow diagram represents separate time points instead of a mathematical flow.
Figure 2.
Figure 2.. International Knee Documentation Committee (IKDC) Subjective Knee Form Questionnaire Scores During Follow-up
The IKDC score for knee function per time point, shown with the box representing the IQR and median score indicated as the line within the box. The error bars indicate the 95% CIs.
Figure 3.
Figure 3.. Between-Group Intervention Effects Indicated With International Knee Documentation Committee (IKDC) Subjective Knee Form Questionnaire for Physical Therapy (PT) vs Surgery
Crude (A) and adjusted (B) noninferiority threshold refers to the minimal important change on the IKDC questionnaire (11 points). The squares indicate the between-group differences with 95% CIs. A positive value indicates greater improvement on the IKDC questionnaire in the arthroscopic partial meniscectomy group compared with the physical therapy group. Because none of the 95% CIs in the crude intervention effect crossed this noninferiority threshold, no clinically meaningful difference between physical therapy and surgery was observed.
See this image and copyright information in PMC

Comment in

References

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