Summary: Arthroscopic partial meniscectomy is among the most frequently performed procedures in orthopaedic surgery. This trial is consistent with current consensus that surgery should not be first line treatment in middle-aged and older people with meniscal tears.
ESCAPE was a large (n=321) multi-site randomised controlled trial conducted in the Netherlands. Participants were aged 45 to 70 years with non-obstructive meniscal tears (ie, no locking of the knee joint). People with knee instability, severe osteoarthritis, and body mass index > 35 kg/m2 were excluded. Participants were randomised to either physiotherapy or surgery. The physiotherapy protocol consisted of 16 sessions of exercise therapy over 8 weeks focused on coordination and closed kinetic chain strengthening exercises. The primary outcome measure was patient reported knee function (the International Knee Documentation Committee Subjective Knee Form) rated on a 0-100 point scale at the 2-year follow-up.
A non-inferiority margin of 8 points was pre-specified in the trial protocol. The confidence limits for the difference between the two treatment groups did not exceed this margin, therefore the authors concluded that that exercise-based physiotherapy was not inferior to surgery for people with knee pain and non-obstructive meniscal tears. The best estimate of the effect of physiotherapy was that it is 3.6 points less effective than surgery, and at worst physiotherapy could be as much as 6.5 points less effective. This is considered a very small difference as the outcome measure uses a 100-point scale. Adverse events occurred in 18 participants in the surgery group and 12 in the physiotherapy group. Costs were not evaluated.
29% of the physiotherapy group ended up having surgery. A secondary, ‘as treated’, analysis with these participants in a third ‘delayed arthroscopic partial menisectomy’ group, revealed outcomes similar to physiotherapy alone. Further research needs to explore why such a significant proportion of participants were not satisfied with initial non-surgical management.
Listen to Norman Swan interview Victor van de Graaf (an orthopaedic surgery resident and doctoral student from the Onze Lieve Vrouwe Gasthuis Hospital, Amsterdam who is the lead author of this trial) for ABC Radio National’s Health Report.
van de Graaf VA et al. Effect of early surgery versus physical therapy on knee function among patients with nonobstructive meniscal tears: the ESCAPE randomized clinical trial. JAMA 2018;320(13):1328-37