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Clinician Article

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

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• Noorduyn JCA
• van de Graaf VA
• Willigenburg NW
• Scholten-Peeters GGM
• Kret EJ
• van Dijk RA, et al.

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Clinical Comments

General Internal Medicine-Primary Care(US)

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

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

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

We are operating too much! Physiotherapy is as good.