Knee Arthroscopy – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to:

  • Knee debridement and washout for osteoarthritis (knee arthroscopy)
  • A surgical procedure for inspection and treatment of problems arising in the knee joint such as inflammation or an injury. It can include repair or removal of any damaged tissue or cartilage. It has been used extensively in the past to diagnose knee problems but this is no longer appropriate due to the invasive nature of the procedure and the increasing access to less invasive diagnostic methods such as MRI.
  • It is important to ensure that the evidence base is robust so that patients are not exposed to the risks without good evidence of benefit. It is important for the NHS to optimise the safety and cost-effectiveness of procedures to ensure maximum benefit for the risks and costs involved. The figures suggest that this could represent an area of improvement in cost-effectiveness and possible cost saving.
  • The most recent Royal College of Surgeons commissioning guide states that knee arthroscopy, lavage and debridement should NOT be offered to patients with non-mechanical symptoms of pain and stiffness1. This approach is supported by many CCGs in England, including ones local to Vale of York, which do not support the routine funding of diagnostic knee arthroscopy

This commissioning statement does not refer to:

  • Red flag symptoms or signs which include:
    • Recent trauma
    • Constant progressive non-mechanical pain (particularly at night)
    • Previous history of cancer, long term oral steroid use
    • History of drug abuse or HIV, fever, being systematically unwell
    • Recent unexplained weight loss
    • Persistent severe restriction of joint movement
    • Widespread neurological changes, and structural deformity.
    • Infection, carcinoma, nerve root impingement, bony fracture and avascular necrosis

Status

Eligibility Criteria ​​

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:

  • Removal of loose body
  • Meniscal repair or resection / repair of chondral defects
  • Ligament reconstruction/repair (including lateral release)
  • Synovectomy / symptomatic plica
  • To assist selection of appropriate patients for uni-compartmental knee replacement

Knee arthroscopy should NOT be carried out for any of the following indications:

  • Investigation of knee pain (MRI is a less invasive alternative for the investigation of knee pain)
  • Treatment of osteoarthritis including arthroscopic lavage and debridement.

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).

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

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

  • "The small inconsequential benefit seen from interventions that include arthroscopy for the degenerative knee is limited in time and absent at one to two years after surgery. Knee arthroscopy is associated with harms. Taken together, these findings do not support the practice of arthroscopic surgery for middle aged or older patients with knee pain with or without signs of osteoarthritis14. The Royal College of Surgeons/British Orthopaedic Association commissioning guide points out that "osteoarthritis may not be progressive and most patients will not need surgery, with their symptoms adequately controlled by non-surgical measures as outlined by NICE1."

Regarding knee arthroscopy, it states that lavage and debridement should be considered in patients:

  • With clear history of mechanical symptoms e.g. locking that have not responded to at least 3 months of non-surgical treatment
  • Where a detailed understanding of the degree of compartment damage within the knee is required, above that demonstrated by imaging, when considering patients for certain surgical interventions (e.g. high tibial osteotomy)

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.

Restricted procedures
  • For some interventions, the evidence identifies a lack of effect or there is insufficient evidence to warrant their use. There is currently no NICE guidance on the use of many procedures but, for the procedures that have been assessed, those not recommended by NICE will not be funded without IFR approval.
  • There is evidence (including from a Cochrane systematic review) that lavage does not improve patient outcome compared to sham2, 3, 24, 25, 26 and NICE does not recommend lavage2. NICE recommends knee meniscus replacement with biodegradable scaffold only with special arrangements for clinical governance, consent and audit or research27. NICE currently recommends that mosaicplasty should not be used without special arrangements for consent and audit or research28.
  • NICE does not currently recommend autologous chondrocyte implantation for the treatment of articular cartilage defects of the knee joint except in the context of on-going or new clinical studies29. NICE recommends that arthroscopic trochleoplasty for patellar instability should only be used with special arrangements for clinical governance, consent and audit or research30. There is some evidence that debridement is ineffective3, 24, 25, but NICE recommends that debridement may be appropriate in cases where there is mechanical locking3.
Restricted use of MRI
  • MRI is a good diagnostic tool22, but may be inaccurate when used by less experienced staff23 and its use is, therefore, restricted to secondary care or specialists working in CCG commissioned MSK services for this indication.
  • Adapted (and updated) from evidence review in Knee arthroscopy for chronic knee pain Cambridgeshire and Peterborough CCG31, with thanks to Dr Raj Lakshman, Consultant Lead in Healthcare
Shared decision-making
  • A letter following the recent BMJ editorial suggests that the overtreatment of knee pain with arthroscopy could be solved through the use of shared decision making32. The NHS/BMJ aid for knee arthritis clearly states that arthroscopy for lavage and/or debridement doesn't make much difference to pain, increase mobility around or stop symptom progression33. The British Orthopaedic Association recently claimed that GPs were over-diagnosing patients with non-arthritic complaints and referring them on for surgery (instead of prescribing exercise) with the expectation that the keyhole procedure would 'cure' the problem, so that too many patients were undergoing needless arthroscopy. Easy access to MRI is also likely to be leading to over diagnosis of meniscal tears and subsequent overtreatment.
  • "Shared decision-making for the management of knee pain should begin in the GP surgery and continue through the patient's treatment. Given the research findings, it would be difficult to see why patients who are adequately supported in the decision-making process would be choosing surgery over physiotherapy."

References

  1. Painful osteoarthritis of the knee - Royal college of surgeons/BOA commissioning guide November 2013 https://www.boa.ac.uk/wp-content/uploads/2014/08/Painful-osteoarthritis-of-the-knee_Revised-final.pdf
  2. National Institute for Health and Clinical Excellence – Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis – guidance issue date: 22 August 2007. http://www.nice.org.uk/IPG230
  3. Care and Management of Osteoarthritis NICE Clinical Guidelines CG177 Feb 2014 http://www.nice.org.uk/guidance/CG177/chapter/1-Recommendations#referral-for-consideration-of-joint-surgery-
  4. Moseley JB, O'Malley K, Petersen NJ, et al. A controlled trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med 2002;347:81-8.
  5. Sihvonen R et al for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. N Engl J Med 2013;369:2515-24.
  6. Katz J N et al Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. N Engl J Med 2013; 368(18): 1675-84.
  7. Herrlin S V et al Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc (2013) 21:358–364.
  8. Hing C B, Smith T O, Donell S, Song F. Surgical versus non-surgical interventions for treating patellar dislocation. The Cochrane database of systematic reviews 2011.
  9. Kettunen J A et al Knee arthroscopy and exercise versus exercise only for chronic patellofemoral pain syndrome: a randomized controlled trial. BMC Medicine 2007;5:38.
  10. Jameson S S et al The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS. J Bone Joint Surg Br. 2011 Oct;93(10):1327-33.
  11. Ashraf A et al Acute and subacute complications of pediatric and adolescent knee arthroscopy. Arthroscopy. 2014 Jun;30(6):710-4.
  12. Petty C A, and Lubowitz J H. Does Arthroscopic Partial Meniscectomy Result in Knee Osteoarthritis? A Systematic Review With a minimum of 8 Years' Follow-up. Arthroscopy 2011; 27(3):419-424.
  13. Piedade S R et al Is previous knee arthroscopy related to worse results in primary total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc 2009; 17:328–333.
  14. Thorlund J B, Juhl C B, Roos E M, Lohmander L S. Arthroscopic surgery for degenerative knee disease: systematic review and meta analysis of benefits and harms. BMJ 2015;350:h2747. http://www.bmj.com/content/350/bmj.h2747
  15. Price A, Beard D. Arthroscopy for degenerate meniscal tears of the knee. BMJ 2014;348:g2382.
  16. Arthroscopic surgery for degenerative knee: overused, ineffective and potentially harmful BMJ2015; 350 doi: http://dx.doi.org/10.1136/bmj.h2983 (Published 16 June 2015)
  17. Arthroscopic surgery for knee pain. A highly questionable practice without supporting evidence of even moderate quality BMJ2016; 354 doi: http://dx.doi.org/10.1136/bmj.i3934 ( Published 20 July 2016)
  18. Khan M et al M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ 2014;186:1057-64.
  19. Kise NJ et al Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ2016;354:i3740.
  20. Guermazi A et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ2012;345:e5339.
  21. Prasad V, Cifu A, Ioannidis JP. Reversals of established medical practices: evidence to abandon ship. JAMA2012;307:37-8.
  22. Crawford R et al. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. British medical bulletin 2007;84:5-23.
  23. Bryan S et al. The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint. Health Technol Assess 2001;5(27):1-95.
  24. Laupattarakasem W et al. Arthroscopic debridement for knee osteoarthritis. The Cochrane database of systematic reviews 2008.
  25. Health Quality Ontario. Arthroscopic lavage and debridement for osteoarthritis of the knee: an evidence-based analysis. Ontario health technology assessment series 2005;5(12):1-37.
  26. Reichenbach S et al. Joint lavage for osteoarthritis of the knee. The Cochrane database of systematic reviews 2010.
  27. NICE Interventional Procedure Guidance 430. Partial replacement of the meniscus of the knee using a biodegradable scaffold. 2012.
  28. NICE Interventional Procedure Guidance 162. Mosaicplasty for knee cartilage defects. 2006.
  29. NICE Technology Appraisal 89. The use of autologous chondrocyte implantation for the treatment of cartilage defects in knee joints. 2005.
  30. NICE Interventional Procedure Guidance 474. Arthroscopic trochleoplasty for patellar instability. 2014.
  31. Knee arthroscopy for chronic knee pain. Cambridgeshire and Peterborough CCG policy approved Sept 2015 http://www.cambsphn.nhs.uk/CCPF/PHPolicies.aspx
  32. Arthroscopic surgery for knee pain; where is the shared decision making? Letter from Dr S Finnikin GP http://www.bmj.com/content/354/bmj.i3934/rr/927387
  33. Osteoarthritis of the knee shared decision-making tool
  34. Orthopaedic groups apologise after claiming that 'GPs not doing their job properly' http://www.pulsetoday.co.uk/clinical/more-clinical-areas/musculoskeletal/orthopaedic- groups-apologise-after-claiming-that-gps-not-doing-their-job-properly/20010420.fullarticle
  35. NICE Interventional Procedure Guidance 474. Arthroscopic trochleoplasty for patellar instability. 2014.

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA3 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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