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Original Investigation
October 2, 2018

Effect of Early Surgery vs Physical Therapy on Knee Function Among Patients With Nonobstructive Meniscal TearsThe ESCAPE Randomized Clinical Trial

Author Affiliations
  • 1Department of Orthopedic Surgery, Joint Research, OLVG, Amsterdam, the Netherlands
  • 2Department of Orthopedic Surgery, Clinical Orthopedic Research Center–mN, Diakonessenhuis, Utrecht, the Netherlands
  • 3Department of Obstetrics and Gynecology, School of Medicine, Monash University, Melbourne, Victoria, Australia
  • 4Department of Orthopedic Surgery, UMC Utrecht, Utrecht, the Netherlands
  • 5Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
  • 6currently with Department of Clinical Epidemiology and Biostatistics, Amsterdam UMC, Amsterdam, the Netherlands
  • 7Institute of Health Science of the Vrije Universiteit, Amsterdam, the Netherlands
JAMA. 2018;320(13):1328-1337. doi:10.1001/jama.2018.13308
Key Points

Question  Is physical therapy noninferior to early surgery with arthroscopic partial meniscectomy for improving knee function among patients with nonobstructive meniscal tears?

Findings  In this noninferiority randomized clinical trial that included 321 patients, knee function that was measured by a self-administered questionnaire improved by 20.4 points in the physical therapy group vs 26.2 points in the early surgery group over a follow-up period of 24 months. The difference between the 2 treatment groups did not exceed the noninferiority margin of 8 points.

Meaning  These results demonstrate noninferiority of physical therapy compared with early surgery with arthroscopic partial meniscectomy for improving self-reported knee function in patients with nonobstructive meniscal tears.

Abstract

Importance  Despite recent studies suggesting arthroscopic partial meniscectomy (APM) is not more effective than physical therapy (PT), the procedure is still frequently performed in patients with meniscal tears.

Objective  To assess whether PT is noninferior to APM for improving patient-reported knee function in patients with meniscal tears.

Design, Setting, and Participants  Noninferiority, multicenter, randomized clinical trial conducted in 9 hospitals in the Netherlands. Participants were aged 45 to 70 years with nonobstructive meniscal tears (ie, no locking of the knee joint). Patients with knee instability, severe osteoarthritis, and body mass index greater than 35 were excluded. Recruitment took place between July 17, 2013, and November 4, 2015. Participants were followed up for 24 months (final participant follow-up, October 11, 2017).

Interventions  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 over 8 weeks focused on coordination and closed kinetic chain strength exercises.

Main Outcomes and Measures  The primary outcome was change in patient-reported knee function on the International Knee Documentation Committee Subjective Knee Form (range, 0 to 100; from worse to best) from baseline over 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 α of .025. The primary analysis followed the intention-to-treat principle.

Results  Among 321 patients who were randomized (mean [SD] age, 58 [6.6] years; 161 women [50%]), 289 (90%) completed the trial (161 women and 158 men). In the PT group, 47 participants (29%) had APM during the 24-month follow-up period, and 8 participants randomized to APM (5%) did not have APM. Over a 24-month follow-up period, knee function improved in the APM group 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 overall between-group difference was 3.6 points (97.5% CI, −∞ to 6.5; P value for noninferiority = .001). Adverse events occurred in 18 participants in the APM group and 12 in the PT group. Repeat 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) were the most frequent adverse events.

Conclusions and Relevance  Among patients with nonobstructive meniscal tears, PT was noninferior to APM for improving patient-reported knee function over a 24-month follow-up period. Based on these results, PT may be considered an alternative to surgery for patients with nonobstructive meniscal tears.

Trial Registration  ClinicalTrials.gov Identifier: NCT01850719

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