ESCAPE long-term findings: Surgery still no better than PT for meniscal tears

In the 5-year follow-up of the ESCAPE trial, exercise-based physical therapy (PT) remained noninferior to arthroscopic partial meniscectomy (APM) for the treatment of symptomatic, degenerative, MRI-confirmed meniscal tears.

“[Extending] the follow-up period is important because the durability of the result is relevant for this patient population as they enter the age group most appropriate for arthroplasty,” said Drs Brian Hallstrom and Ramzy Meremikwu from the University of Michigan, Ann Arbor, Michigan, US, in an accompanying editorial. [JAMA Network Open 2022;5:e2220405]

“[In ESCAPE,] the improvement in knee function experienced by patients … over the first 2 years was maintained at the 5-year follow-up,” said the study investigators.

 

Patient-reported knee function

At 5 years, mean improvements on the IKDC* questionnaire score for knee function were 29.6 and 25.1 points in the respective APM and PT arms. Crude and adjusted mean between-group differences were 2.8 and 3.4 points, respectively (p_{noninferiority}<0.001 for both). [JAMA Network Open 2022;5:e2220394]

“A positive between-group value indicates greater mean improvement on the IKDC questionnaire [with APM vs PT] ,” the researchers noted. “However, the … differences are significantly smaller than the noninferiority threshold of 11 points, indicating that PT is noninferior to APM.”

In the as-treated analysis, overall crude difference on the IKDC questionnaire score between APM and PT was 2.4 points (p_{noninferiority}<0.001), indicating greater improvement with the former than the latter. Conversely, between PT and delayed surgery, the difference was −3.8 points (p_{noninferiority}<0.001), signifying greater mean improvement with PT vs delayed surgery. “These between-group differences were significantly different from the noninferiority threshold, again indicating that PT was noninferior to APM,” said the researchers.

 

Radiographic knee osteoarthritis

Based on the OARSI** sum score, radiographic knee osteoarthritis progressed by at least 1 point in about half of participants in both arms at 5 years (mean progression, 1.1 points). The between-group difference (0.1 point) was not clinically or significantly meaningful.

In the as-treated analysis, mean progression in the OARSI sum score was similar across arms (1.1, 0.8, and 1.7 points in the respective APM, PT, and delayed-surgery arms), yielding no significant difference between arms (p=0.16).

 

The regimens

A total of 321 patients (mean age 58 years, 50 percent female) were randomized 1:1 to APM or 16 30-minute sessions of exercise-based PT. About 90 percent of participants completed the 5-year follow-up. During follow-up, 32 percent of those receiving PT underwent delayed APM due to persistent knee symptoms, with most (n=44) having their procedures done within the first 2 years of follow-up.

APM included a standardized intra-articular evaluation*** of the knee joint. The affected part of the meniscus was removed until a stable, solid meniscus remained. Postop instructions included a home exercise programme. PT referral was given to those who had delayed recovery with APM.

The PT treatment protocol consisted of an incremental exercise programme conducted by a physical therapist over an 8-week period. If knee symptoms^# persisted after the programme, additional PT sessions or APM was allowed.

 

PT preferred over surgery

Not all PT recipients appeared satisfied with their treatment, considering those who crossed over to APM. “[Nonetheless, the noninferiority of PT to APM] supports the recommendation that exercise-based PT should be the preferred treatment over surgery for degenerative meniscal tears,” said the researchers.

“[Our] results can assist in the development and updating of current guideline recommendations about treatment for patients with a degenerative meniscal tear,” they added. “Future research should focus on pooling the 5-year data on knee function and knee OA from separate trials to strengthen clinical guidelines.”

“[Moreover,] investigating the efficacy of exercise-based PT compared with a wait-and-see policy or no treatment can strengthen policymakers to invest in PT and enhance further de-implementation of APM for degenerative meniscal tears,” they said.

“Arthroscopy is also expensive and, when without benefit, the balance of the value equation is negative,” added Hallstrom and Meremikwu.