Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal Tears
The ESCAPE Randomized Clinical Trial, JAMA. 2018, Victor A. van de Graaf et al.
In this randomized clinical study encompassing 321 patients, the knee function measured with a self-administered questionnaire improved by 20.4 points in the physiotherapy group versus 26.2 points in the early surgery group during a follow-up period of 24 months.
These results demonstrate non-inferiority of physiotherapy compared to early surgery with arthroscopic partial meniscectomy to improve the self-reported knee function in patients with non-obstructive meniscal tears.
Despite recent studies suggesting that arthroscopic partial meniscectomy (APM) is not more effective than physiotherapy (PT), the procedure is still often performed in patients with meniscal tears. The evaluation examines whether PT is non-inferior to APM for improving the knee function reported by the patient in patients with meniscal tears.
This noninferiority, multicenter, randomized clinical study was performed in 9 hospitals in the Netherlands. The participants were 45-70 years old with non-obstructive meniscal tears (ie no locking of the knee joint). Patients with instability in the knee, severe osteoarthritis and body mass index greater than 35 were excluded. Recruitment took place between 17 July 2013 and 4 November 2015. Participants were monitored for 24 months (follow-up last participant, 11 October 2017).
Three hundred twenty-one participants were randomly assigned to APM (n = 159) or a predefined PT protocol (n = 162). The PT protocol consisted of 16 sessions of exercise therapy for 8 weeks focused on coordination and exercises with closed kinetic chain strength.
The primary result was the change in the knee function reported by the patient on the Knee Documentation Committee, the Subjective Knee (range, 0 to 100, worse to best) from the baseline during a 24-month follow-up period. The noninferiority margin was defined as a difference between treatment groups of 8 points and was assessed with a 1-sided a of .025. The primary analysis followed the intention-to-treat principle.
Among 321 patients randomized (mean [SD] age, 58 [6.6] years, 161 women [50%]), 289 (90%) completed the study (161 women and 158 men). In the PT group, 47 participants (29%) had APM during the follow-up period of 24 months. Eight participants who were randomized to APM (5%) did not have APM. During a follow-up period of 24 months, the knee function in the APM group improved by 26.2 points (from 44.8 to 71.5) and in the PT group by 20.4 points (from 46.5 to 67 7). The total difference between the groups was 3.6 points (97.5% CI, -∞ to 6.5, P-value for non-inferiority = 0.001). Adverse events occurred in 18 participants in the APM group and 12 in the PT group. The most common side effects were repeated surgery (3 in the APM group and 1 in the PT group) and additional outpatient visits for knee pain (6 in the APM group and 2 in the PT group).
This multicenter RCT showed that, in patients older than 45 years old with knee pain and nonobstructive meniscal tears, PT was noninferior to APM for knee function over a 24-month follow-up period. Based on these results, PT can be considered as an alternative to surgery for patients with non-obstructive meniscal tears.