Exercise-based physical therapy remained non-inferior to arthroscopic partial meniscectomy for the treatment of degenerative meniscal tears, according to longer-term data from the ESCAPE trial, suggesting that physical therapy is the treatment of choice over surgery.
At 5 years, patient-reported knee function after 16 sessions of physical therapy was not inferior to that observed after surgery, with a difference between the groups of 3.5 points on the 100-point International Knee Documentation Committee Subjective Knee Form (95% CI 0.7-6.3, p<0.001 for non-inferiority) on intention-to-treat analysis, according to sports scientist Julia Noorduyn, MSc, of OLVG Amsterdam, The Netherlands, and colleagues.
For the surgery and exercise groups, respectively, the mean improvement from baseline was 29.6 and 25.1 points at 5 years. The progression of knee osteoarthritis, assessed by radiography, was equally low in the two groups, Noorduyn’s team reported in JAMA network opened†
The most important findings from the first 2 years of ESCAPE are therefore also maintained in the longer term. These results may provide future guideline recommendations for treating patients with degenerative meniscus tears, the researchers suggested.
In the study, there was a 32% crossover rate of people who underwent delayed surgery after initial physical therapy — usually within the first year. “These figures show that not all patients experience satisfactory results after physical therapy,” acknowledge Noorduyn and colleagues.
However, on axis-treated analysis, physical therapy was still not inferior to arthroscopic partial meniscectomy in terms of 5-year outcomes.
“Surgery has been described as the ultimate placebo,” said orthopedic surgeons Brian Hallstrom, MD, and Ramzy Meremikwu, MD, both of the University of Michigan at Ann Arbor.
“While there have been multiple randomized clinical trials that have failed to demonstrate efficacy of knee arthroscopy for knee osteoarthritis or debridement of partial degenerative menisci, we are still studying these treatments, perhaps looking for a different outcome,” the duo wrote in a statement. accompanying editorial†
Hallstrom and Meremikwu also emphasized that knee surgery is “not benign” because the procedure is costly and is associated with accelerated progression of osteoarthritis of the knee.
Indeed, a 2014 study found that: knee surgery was associated with an increased risk of osteoarthritis in the same knee, which often developed within 1 year of surgery to repair meniscal cartilage tears.
The randomized ESCAPE study collected data from nine orthopedic departments in hospitals in the Netherlands from 2013 to 2020.
Eligible participants were individuals with degenerative meniscal tears. Those with a locked knee, trauma requiring acute surgery, associated index knee injuries, severe structural osteoarthritis of the knee, or a BMI of 35 or greater were excluded.
Of the 321 initial participants aged 45 to 70 years (mean age 58 years, 50.2% females), 278 completed 5-year follow-up, with a mean follow-up of 61.8 months.
Physical therapy and surgical groups shared similar baseline characteristics.
Noorduyn’s team cautioned that ESCAPE did not record reasons why people did not participate in follow-up questionnaires or X-rays, and the loss to follow-up could be related to selection bias. Additional non-invasive treatments for knee pain were also not registered.
Still, the study’s findings are consistent with the knee surgery literature, Hallstrom and Meremikwu suggested.
“Multiple studies, including several using sham surgery as a control, have repeatedly shown over the past two decades that surgery is not superior to physical therapy, but the problem and use of surgery persist,” they wrote. The current study shows “again that arthroscopy is no better than nonsurgical treatment of meniscus tears.”
The research was financed by grants from ReumaNederland, ZonMw, Zilveren Kruis Zorgverzekeringen and the Foundation for Medical Research of the OLVG, Amsterdam. The costs of the physiotherapy sessions were reimbursed by the Achmea Healthcare Foundation.
Noorduyn reported receiving grants from the Netherlands Organization for Health Research and Development, the Achmea Healthcare Foundation, the OLVG Medical Research Foundation, the OLVG Science Committee and the Dutch Arthritis Association.
Hallstrom reported receiving partial salary support paid by Michigan Blue Cross Blue Shield to the University of Michigan for his work as co-director of the Michigan Arthroplasty Registry Collaborative Quality Initiative.
Meremikwu had no disclosures.
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