Exercise-based physical therapy remained noninferior to arthroscopic partial meniscectomy for treating degenerative meniscal tears, according to longer-term data from the ESCAPE trial, suggesting physical therapy be the preferred treatment over surgery.

By the 5-year mark, patient-reported knee function after 16 sessions of physical therapy was non-inferior to that observed after surgery, with a between-group difference of 3.5 points on the 100-point International Knee Documentation Committee Subjective Knee Form (95% CI 0.7-6.3, P<0.001 for noninferiority) on intention-to-treat analysis, according to movement scientist Julia Noorduyn, MSc, from OLVG Amsterdam, the Netherlands, and colleagues.

For the surgery and exercise therapy groups, respectively, mean improvement from baseline was 29.6 and 25.1 points at 5 years. Progression of knee osteoarthritis, assessed through radiography, was similarly low among the two groups, Noorduyn’s team reported in JAMA Network Open.

The main findings from ESCAPE’s first 2 years are thus maintained in the longer run. These results may inform future guideline recommendations for treating patients with degenerative meniscal tears, the investigators suggested.

In the trial, there was a 32% crossover rate of people undergoing delayed surgery after initial physical therapy — mostly within the first year. “These numbers demonstrate that not all patients experience satisfying results following physical therapy,” Noorduyn and colleagues acknowledged.

On as-treated analysis, however, physical therapy was still not inferior to arthroscopic partial meniscectomy in terms of 5-year outcomes.

“Surgery has been described as the ultimate placebo,” according to orthopedic surgeons Brian Hallstrom, MD, and Ramzy Meremikwu, MD, both of the University of Michigan in Ann Arbor.

“Although there have been multiple randomized clinical trials showing no efficacy of knee arthroscopy for knee osteoarthritis or debridement of partial degenerative menisci, we are still studying these treatments, perhaps searching for a different outcome,” the duo wrote in an accompanying editorial.

Hallstrom and Meremikwu also emphasized that knee surgery is “not benign,” as the procedure is costly and associated with accelerated progression of knee osteoarthritis.

Indeed, one study from 2014 showed that knee surgery was associated with an increased risk of osteoarthritis in the same knee, often developing within 1 year of surgery to repair meniscus cartilage tears.

The randomized ESCAPE trial collected data from nine orthopedic departments across hospitals in the Netherlands from 2013 to 2020.

Eligible participants were individuals with degenerative meniscal tears. Those with locked knee, trauma requiring acute surgery, associated injuries on the index knee, severe structural knee osteoarthritis, or a BMI of 35 or greater were excluded.

Out of 321 initial participants age 45 to 70 years (mean age 58 years, 50.2% women), 278 completed the 5-year follow-up, with a mean follow-up of 61.8 months.

Physical therapy and surgical groups shared similar baseline characteristics.

Noorduyn’s team cautioned that ESCAPE did not register reasons why people did not participate in follow-up questionnaires or radiographs, and the loss to follow-up could be related to selection bias. Additional noninvasive treatments for knee pain were also not recorded.

Even so, the findings from the trial are in line with the literature on knee surgery, Hallstrom and Meremikwu suggested.

“Multiple studies, including several with sham surgeries as a control have shown repeatedly over the previous 2 decades that surgery is not superior to physical therapy, yet the issue and use of surgery persist,” they wrote. The current study shows “again that arthroscopy is not better than nonsurgical management of meniscal tears.”

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