LAUSR

The study by Noorduyn et al 1 reports on the 5-year follow-up of the patients in the ESCAPE trial, whichcomparedphysicaltherapywitharthroscopyfordegenerativemeniscaltears.TheESCAPEtrial included patients older than 45 years who were randomized to physical therapy or arthroscopy in a noninferiority analysis. This trial was previously reported at 2 years of follow-up. The extension of 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. Another strength of the present report, as compared with the 2-year results, is the addition of the as-treated analysis. Without this analysis, the reader would struggle with the 32% of patients who crossed over to the arthroscopy group (the delayed surgery group), which showed that those patients fared worse than the ones who did not initially receive surgery. The data on progression of the disease is also an important addition for patients and physicians involved in shared decision-making. Given these points, the issue really is why we are comparing arthroscopy with physical therapy for this patient population when the inefficacy of arthroscopy has been shown. When Moseley et al 2 published their landmark study of arthroscopy vs sham surgery in 2002, they reported that arthroscopy was no better than placebo for knee osteoarthritis. Outcomes were assessed over a 2-year follow-up period with reported improvement in function at 12 months for both the arthroscopy and placebo groups, but with no statistically significant difference between the groups.Strengthsofthisstudyincludelimitedlosstofollow-upovera2-yearperiodandtheidentical design of the treatments (lavage and debridement) to their counterparts in practice. In addition, Brignardello-Petersen et al 3 published a systematic review of 13 randomized clinical trials and 12 observational studies, comparing the outcomes of knee arthroscopy vs conservative management, including physical therapy, in patients with degenerative knee disease. The analysis found very small reductioninpainorimprovementinfunctioninpatientsat3monthsandnoimportantdifferenceat 2 years compared with conservative treatment.