Escaping the Scalpel: In-depth evidence to change clinical practice for patients with a degenerative meniscal tear

The ESCAPE trial is a randomized clinical trial comparing meniscus surgery with physical therapy in patients with a degenerative meniscal tear. This thesis is an in-depth analysis and continuation of the ESCAPE trial, aiming to advance evidence-based practice for patients with a degenerative meniscal tear. We investigated the responsiveness and minimal important change of the International Knee Documentation Committee Subjective Knee Form, the primary outcome of the ESCAPE trial. These measurement properties are important for assessing intervention effects in clinical practice and randomized controlled trials. This study showed that the IKDC is responsive to change among patients aged 45 to 70 years with meniscus tears, with an MIC of 10.9 points. This strengthens the value of the IKDC in quantifying treatment effects in this population. Patient-specific activities have not yet been considered as part of the evaluation of treatment effects in those with a meniscus tear. We compared meniscus surgery with physical therapy in patients with a degenerative meniscal tear using the Dutch equivalent of the patient-specific functioning score. measure over a period of 2 years. We also calculated the MIC for the PSFS using an anchor-based method to interpret the results. In our study population, we found a MIC of 2.5 points. The crude overall between-group difference showed a difference of 0.6 points (95% CI, –1.0 to –0.2; p = .004) between both groups. Although statistically significant, this difference between meniscus surgery and physical therapy in terms of patients’ specific activities is not clinically meaningful. In the current guidelines, exercise-based physical therapy is the recommended treatment in patients over 45 years old with a degenerative meniscus tear. However, between 1.9 and 36% of the patients randomized to physical therapy still opt for meniscus surgery. We developed and validated two multivariable prognostic models to identify those patients with a degenerative meniscal tear who will undergo surgery within 6 months and within 24 months following physical therapy. At 24 months, patients were more likely to opt for meniscus surgery when they had worse knee function and a lower level of education at baseline. Both models had a low explained variance (16% and 11%, respectively) and a poor discriminative ability. The non-responders to physical therapy could not accurately be predicted by our prognostic models. To select the best treatment (i.e. meniscus surgery or exercise-based physical therapy) for an individual patient it is important to quantify the expected benefit of one treatment over the other. We introduced a novel approach in musculoskeletal research, a marker-by-treatment analysis. We found that general physical health, pain during activities, knee function, BMI and age were potential treatment selection markers. While some marker-based thresholds could be identified at 3, 12 and 24 months follow-up, none of the baseline characteristics were consistent markers at all three follow-up times. This novel in-depth analysis did not result in clear clinical subgroups of patients who are substantially more likely to benefit from either surgery or physical therapy. Finally, we compared longer term effectiveness of meniscus surgery and exercise-based physical therapy on patient reported knee function and progression of knee osteoarthritis in patients with a degenerative meniscus tear. We assessed patient-reported knee function on the IKDC over 5 years follow-up based on the intention-to-treat principle, with a non-inferiority threshold of 11 points (based on the MIC determined in chapter 2 in our study population). The between-group difference was 2.8 points (95%CI: -0.9 to 6.5; p-value for non-inferiority