This page was printed from The OSCAR website at
Only the electronic version is maintained, once printed this is no longer a controlled document
This commissioning statement refers to:
This commissioning statement does not refer to:
Knee arthroscopy in secondary care is commissioned on a restricted basis. Cases will only be funded if they meet the criteria below:
Arthroscopy of the knee can be undertaken where a competent clinical examination (or MRI scan if there is diagnostic uncertainty or red flag1 symptoms/signs/conditions) has demonstrated clear evidence of an internal joint derangement (meniscal tear, ligament rupture or loose body) and where conservative treatment has failed or where it is clear that conservative treatment will not be effective.
Knee arthroscopy can therefore be carried out for:
Knee arthroscopy should NOT be carried out for any of the following indications:
In line with NICE guidance CG177; this should not be offered as part of treatment for osteoarthritis unless the individual has knee osteoarthritis with a clear history of mechanical locking (not gelling, 'giving way')
In rare circumstances, intractable knee pain may benefit from arthroscopic treatment (subject to agreement by exceptional cases panel Prior Approval).
For patients with non-traumatic knee injury, evidence shows that, on average, conservative treatment is as effective as arthroscopic knee surgery for some procedures. As long ago as 2002, a controlled trial addressing knee arthroscopy, using placebo or "sham" surgery as a comparator, showed no benefit4.
Partial meniscectomy surgery showed no advantage over sham in one RCT of patients aged 35-65 years with degenerative meniscal tears without osteoarthritis5 and no advantage over physical therapy in two RCTs of older patients (>45 years) with osteoarthritis6, 7. In a systematic review of RCTs of young patients (mean age ~20 years) with a first occurrence of patellar dislocation, there was no conclusive advantage of surgical treatments compared with non-surgical treatments8. In an RCT of patients with patellarfemoral pain syndrome (18-40 years), mixed arthroscopic procedures and exercise resulted in equivalent improvements compared with exercise alone9.
Although rates of post-operative complications are generally low higher rates have been observed in children and young people10,11. There may also be future knee damage associated with arthroscopic procedures12, 13 and a recent meta-analysis showed that the small benefit from arthroscopic knee surgery seen in middle aged or older patients with knee pain and degenerative knee disease was absent one to two years after surgery and was associated with an increase in significant harms such as deep vein thrombosis, pulmonary embolism, infection and death14. The paper concludes
Regarding knee arthroscopy, it states that lavage and debridement should be considered in patients:
The RCS/BOA guidance also states (in line with NICE guidance) that "Knee arthroscopy, lavage and debridement should NOT be offered for patient with non-mechanical symptoms of pain and stiffness."
More recently, the BMJ has published two editorials about arthroscopic surgery for degenerative knee or knee pain16, 17. They both explore the evidence for benefit and harm and point out that, although this is one of the most common surgical procedures, there is no convincing evidence for the procedure being beneficial beyond the placebo effect.
A series of rigorous trials summarised in two recent systematic reviews and meta-analyses provide clear evidence that arthroscopic knee surgery offers little benefit for most patients with knee pain14, 18.
The most recent linked paper is a comparison between exercise therapy alone and arthroscopic partial meniscectomy alone (without any postoperative rehabilitation) in adults with a degenerative meniscal tear19. The authors found no between group differences in patient reported knee function at the two-year follow-up, but greater muscle strength in the exercise group at three months.
Over time, the indications have extended from locked knees in young patients to all patients of all ages with knee pain and meniscus tears of any sort; tears which, on magnetic resonance imaging, have proved poorly associated with symptoms20.
Essentially, the editorials say, good evidence has been widely ignored. The most recent editorial comments that arthroscopic surgery for knee pain continues unabated, as disinvestments in ineffective treatments are generally slow17, 21. It calls for local commissioners to respond appropriately to the evidence, because "system level measures that result in more appropriate use of scarce medical resources are urgently required".
In addition, it says that "in a world of increasing awareness of constrained resources and epidemic medical waste, what we should not do is ignore the results of rigorous trials and allow continuing widespread use of procedures for which there has never been compelling evidence".
Rationale for up to 12 months of conservative treatment in chronic knee pain. This policy therefore specifies that conservative treatment should primarily be used but, when this fails, referral for surgery is an option. In the trial of meniscal surgery compared with conservative treatment in patients without osteoarthritis, at earlier time points, outcomes favoured surgery, but by 12 months of conservative treatment, outcomes were equivalent5. Therefore, to allow sufficient time for benefits of conservative treatment to be gained, and to allow for any potential natural healing of joint derangements, a minimum 12 months' restriction has been selected for which conservative treatment should be attempted before any referral.
In this trial, cross-over from the conservative group to surgery over 12 months was low (7%). However, in other trials cross-over has been higher (around 30%)5,6 suggesting that some patients will require more urgent surgery. There may be some cases where symptoms re-occur on conservative management and these patients may benefit from surgery15. Therefore, this policy allows for patients with mechanical locking or worsening symptoms to be referred before the 12-month period of conservative management.