An individualized decision between physical therapy or surgery for patients with degenerative meniscal tears cannot be based on continuous treatment selection markers: a marker‐by‐treatment analysis of the ESCAPE study

Knee Surgery Sports Traumatology Arthroscopy, vol. 30, pp. 1937–1948

Abstract

PURPOSE: Marker-by-treatment analyses are promising new methods in internal medicine, but have not yet been implemented in orthopaedics. With this analysis, specific cut-off points may be obtained, that can potentially identify whether meniscal surgery or physical therapy is the superior intervention for an individual patient. This study aimed to introduce a novel approach in orthopaedic research to identify relevant treatment selection markers that affect treatment outcome following meniscal surgery or physical therapy in patients with degenerative meniscal tears. METHODS: Data were analysed from the ESCAPE trial, which assessed the treatment of patients over 45 years old with a degenerative meniscal tear. The treatment outcome of interest was a clinically relevant improvement on the International Knee Documentation Committee Subjective Knee Form at 3, 12, and 24 months follow-up. Logistic regression models were developed to predict the outcome using baseline characteristics (markers), the treatment (meniscal surgery or physical therapy), and a marker-by-treatment interaction term. Interactions with p < 0.10 were considered as potential treatment selection markers and used these to develop predictiveness curves which provide thresholds to identify marker-based differences in clinical outcomes between the two treatments. RESULTS: Potential treatment selection markers included general physical health, pain during activities, knee function, BMI, and age. 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. CONCLUSION: 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. However, this study may serve as an exemplar for other orthopaedic trials to investigate the heterogeneity in treatment effect. It will help clinicians to quantify the additional benefit of one treatment over another at an individual level, based on the patient's baseline characteristics. LEVEL OF EVIDENCE: II.

Authors 41

1. Julia C. A. Noorduyn corresponding

   OLVG · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

   Affiliation as printed

   <!--<label>1</label>--> Department of Orthopedic Surgery, Joint Research OLVG Amsterdam Oosterpark 9 1091 AC Amsterdam The Netherlands

   <!--<label>2</label>--> Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Amsterdam The Netherlands

   Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

   Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

2. Victor A. van de Graaf

   St. Antonius Ziekenhuis · OLVG

   Affiliation as printed

   <!--<label>1</label>--> Department of Orthopedic Surgery, Joint Research OLVG Amsterdam Oosterpark 9 1091 AC Amsterdam The Netherlands

   <!--<label>3</label>--> Department of Orthopedic Surgery St. Antonius Ziekenhuis Utrecht The Netherlands

   Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

   Department of Orthopedic Surgery, St. Antonius Ziekenhuis, Utrecht, The Netherlands

3. Nienke Willemien Willigenburg

   OLVG

   Affiliation as printed

   <!--<label>1</label>--> Department of Orthopedic Surgery, Joint Research OLVG Amsterdam Oosterpark 9 1091 AC Amsterdam The Netherlands

   Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

4. Gwendolijne G. M. Scholten-Peeters

   Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

   Affiliation as printed

   <!--<label>2</label>--> Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Amsterdam The Netherlands

   Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

5. Ben W. Mol

   Monash University

   Affiliation as printed

   <!--<label>4</label>--> Department of Obstetrics and Gynecology, School of Medicine Monash University 246 Clayton Road, Clayton 3168 Melbourne VIC Australia

   Department of Obstetrics and Gynecology, School of Medicine, Monash University, Melbourne, Australia

6. Martijn W. Heymans

   Amsterdam UMC Location Vrije Universiteit Amsterdam

   Affiliation as printed

   <!--<label>5</label>--> Department of Epidemiology and Biostatistics VU University Medical Centre Amsterdam The Netherlands

   Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands

7. Michel Willem Coppieters

   Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

   Affiliation as printed

   <!--<label>2</label>--> Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences Vrije Universiteit Amsterdam, Amsterdam Movement Sciences Amsterdam The Netherlands

   <!--<label>6</label>--> Menzies Health Institute Queensland Griffith University Brisbane and Gold Coast Australia

   Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

   Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

8. Rudolf Wilhelm Poolman Aachen Department of Orthopedic Surgery

   Leiden University · Leiden University Medical Center · OLVG

   Affiliation as printed

   <!--<label>1</label>--> Department of Orthopedic Surgery, Joint Research OLVG Amsterdam Oosterpark 9 1091 AC Amsterdam The Netherlands

   <!--<label>7</label>--> Department of Orthopedic surgery Leiden University Medical Centre Leiden The Netherlands

   Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

   Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands

9. Vanessa A. Scholtes
10. Eduard L.A.R. Mutsaerts
11. Matthijs R. Krijnen
12. Derek F.P. van Deurzen
13. Dirk Jan F. Moojen
14. Coen H. Bloembergen

    Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

15. Arthur de Gast
16. Thom E. Snijders

    Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

17. Jelle J. Halma
18. Daniël B.F. Saris
19. Nienke Wolterbeek Aachen Department of Orthopedic Surgery

    Leiden University · Leiden University Medical Center · OLVG

    Affiliation as printed

    Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

    Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands

20. Camille Neeter

    Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

21. Gino M. M. J. Kerkhoffs
22. Rolf W. Peters
23. Igor C.J.B. van den Brand
24. Suzanne de Vos‐Jakobs

    Griffith University · Elisabeth-TweeSteden Ziekenhuis · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Orthopaedic Surgery , Elisabeth Tweesteden Ziekenhuis , Tilburg , The Netherlands

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

25. Andy B. Spoor

    Onze Lieve Vrouwziekenhuis Hospital · Monash University

    Affiliation as printed

    Department of Orthopaedic Surgery , Onze Lieve Vrouw Ziekenhuis , Aalst , Belgium

    Department of Obstetrics and Gynecology, School of Medicine, Monash University, Melbourne, Australia

26. Taco Gosens

    Griffith University · Amsterdam UMC Location University of Amsterdam · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    . Peters: Department of Trauma Surgery , Academic Medical Center , Amsterdam , The Netherlands

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

27. Wahid Rezaie Aachen Department of Orthopedic Surgery

    Leiden University · Leiden University Medical Center · Amsterdam UMC Location University of Amsterdam · Noordwest Ziekenhuisgroep · OLVG

    Affiliation as printed

    . Peters: Department of Trauma Surgery , Academic Medical Center , Amsterdam , The Netherlands

    bergen: Department of Orthopaedic Surgery , Noordwest Ziekenhu- isgroep , Alkmaar , The Netherlands.

    Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

    Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands

28. Dirk Jan Hofstee

    Onze Lieve Vrouwziekenhuis Hospital

    Affiliation as printed

    Department of Orthopaedic Surgery , Onze Lieve Vrouw Ziekenhuis , Aalst , Belgium

29. Bart J. Burger
    Affiliation as printed

    . Neeter: Fysiken Physical Therapy , Amsterdam , The Netherlands

30. Daniël Haverkamp Aachen Department of Orthopedic Surgery

    Leiden University · Leiden University Medical Center · OLVG

    Affiliation as printed

    Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

    Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands

31. A. M. J. S. Vervest

    Onze Lieve Vrouwziekenhuis Hospital

    Affiliation as printed

    Department of Orthopaedic Surgery , Onze Lieve Vrouw Ziekenhuis , Aalst , Belgium

32. Thijs A. van Rheenen

    Griffith University · Onze Lieve Vrouwziekenhuis Hospital · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Orthopaedic Surgery , Onze Lieve Vrouw Ziekenhuis , Aalst , Belgium

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

33. Anne E. Wijsbek

    Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

34. Ewoud R.A. van Arkel

    Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

35. Bregje J.W. Thomassen

    Amsterdam UMC Location University of Amsterdam · Monash University

    Affiliation as printed

    . Peters: Department of Trauma Surgery , Academic Medical Center , Amsterdam , The Netherlands

    Mol : Department of Obstetrics and Gynaecology , School of Medicine , Monash University , Melbourne , Australia. . Schavemaker:

36. Sheila Sprague

    Griffith University · Amsterdam Movement Sciences · Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Human Movement Sciences, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands

    Menzies Health Institute Queensland, Griffith University, Brisbane and Gold Coast, Australia

37. M. Schavemaker Aachen Department of Orthopedic Surgery

    Leiden University · Leiden University Medical Center · OLVG

    Affiliation as printed

    Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

    Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands

38. Julius Wolkenfelt

    Amsterdam UMC Location Vrije Universiteit Amsterdam

    Affiliation as printed

    Department of Epidemiology and Biostatistics, VU University Medical Centre, Amsterdam, The Netherlands

39. M. Teuwen Aachen Department of Orthopedic Surgery

    Leiden University · Leiden University Medical Center · OLVG

    Affiliation as printed

    Department of Orthopedic Surgery, Joint Research, OLVG Amsterdam, Amsterdam, The Netherlands

    Department of Orthopedic surgery, Leiden University Medical Centre, Leiden, The Netherlands

40. Ise K. Butter
41. Maurits W. van Tulder