Knee Replacement – Criteria Led Commissioning Statement

Scope

  • This commissioning statement refers to:
    • Knee replacement for knee arthritis

Status

Eligibility Criteria

Referral should be when other pre-existing medical conditions have been optimised AND Conservative measures have been exhausted and failed. This will include weight reduction, NSAIDs and analgesics, changing activity, and introducing a walking aid

Please refer to the classification of pain levels and functional limitations in the table below.

Referrals should be made if any one of the three following applies:

  1. The patient complains of intense or severe symptomatology and
    • Has radiological features of severe disease and
    • Has demonstrated disease within all three compartments of the knee (tri-compartmental) or localised to one compartment plus patello-femoral disease (bi-compartmental)
  2. The patient complains of intense or severe symptomatology and
    • Has radiologic features of moderate disease and
    • Is troubled by limited mobility or stability of the knee joint
  3. The patient has severe symptomatology and
    • Has radiological features of slight disease
    • Is troubled by limited mobility or stability of the knee joint.

The patient is fit for surgery with a BMI ≤30. Patients with a BMI >30 should be advised and given appropriate support to address lifestyle factors that would improve their fitness for surgery

There is evidence to show that "Weight loss and exercise combined have been shown to achieve the same level of symptom relief as joint replacement surgery".

BMI is an established measure of weight though it is recognised that muscular people will have a higher BMI that is not thought to be a risk to health (muscle is denser than fat)

  • Waist circumference
    • Obesity can be measured by waist measurements but it is not yet established in UK clinical practice. NHS Choices website states individuals have a higher risk of health problems if waist size is:
      • more than 94cm (37 inches) if you're a man
      • more than 80cm (31.5 inches) if you're a woman
    • Risk of health problems is even higher if your waist size is:
      • more than 102cm (40 inches) if you're a man
      • more than 88cm (34.5 inches) if you're a woman

Referrals will not be accepted if the patient has an Oxford Knee Score greater than or equal to 20. This scoring should be completed in Primary Care prior to referral.

Patients should make shared decisions with clinicians, using decision support such as the NHS Decision Aid for knee osteoarthritis

Evidence suggests that the following patients would be INAPPROPRIATE candidates for knee joint replacement surgery:

  • Where the patient complains of mild joint pain AND has minor or moderate functional limitation
  • Where the patient complains of moderate to severe joint pain AND has minor functional limitation AND has not previously had an adequate trial of conservative management as described above

Patients whom are assessed by the above criteria to be inappropriate for knee replacement surgery should not be listed for surgery.

For Knee Replacement: Classification of Mobility, Stability, Symptomatology, Radiology and Localisation

Variable

Definition

Mobility and Stability

Preserved mobility and stable joint

Preserved mobility is equivalent to minimum range of movement from 0o to 90o. Stable or not lax is equivalent to an absence of slackness of more than 5mm in the extended joint.

Limited mobility and/or stable joint

Limited mobility is equivalent to a range of movement less than 0o to 90o unstable or lax is equivalent to the presence of slackness of more than 5mm in the extended joint.

Symptomatology

Slight

  • Sporadic pain.
  • Pain when climbing/descending stairs.
  • Allows daily activities to be carried out (those requiring great physical activity may be limited).
  • Medication, aspirin, paracetamol or NSAIDs to control pain with no/few side effects.

Moderate

  • Occasional pain.
  • Pain when walking on level surfaces (half an hour, or standing).
  • Some limitation of daily activities.
  • Medication, aspirin, paracetamol or NSAIDs to control with no/few side effects.

Intense

  • Pain of almost continuous nature.
  • Pain when walking short distances on level surfaces or standing for less than half an hour.
  • Daily activities significantly limited.
  • Continuous use of NSAIDs for treatment to take effect.
  • Requires the sporadic use of support systems walking stick, crutches).

Severe

  • Continuous pain.
  • Pain when resting.
  • Daily activities significantly limited constantly.
  • Continuous use of analgesics - narcotics/NSAIDs with adverse effects or no response.
  • Requires more constant use of support systems (walking stick, crutches).

Radiology

Slight

Ahlback grade I.

Moderate

Ahlback grade II and III.

Severe

Ahlback grade IV and V

Localisation

Unicompartmental

Excluded patello-femoral isolated.

Bicompartmental

Unicompartmental plus patello-femoral.

Tricompartmental

Disease affecting all three compartments of the knee.


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

Around 450 patients per 100,000 population will present to primary care with hip pain each year. Of these, 25% will improve within three months and 35% at twelve months; this improvement is sustained8.

20% of adults over 50 and 40% over 80 years report disability from knee pain secondary to osteoarthritis9. The majority of patients present to primary care with symptoms of pain and stiffness, which reduces mobility and with associated reduction in quality of life.

Osteoarthritis may not be progressive and most patients will not need surgery, with their symptoms adequately controlled by non-surgical measures, as outlined by NICE3. Symptoms progress in 15% of patients with hip pain within 3 years and 28% within 6 years8.

When patient's symptoms are not controlled by up to 3 months of non-operative treatment they become candidates for assessment for joint surgery. The decision to have joint surgery is based on the patient's pre-operative levels of symptoms, their capacity to benefit, their expectation of the outcome and attitude to the risks involved. Patients should make shared decisions with clinicians, using decision support such as the NHS Decision Aid for knee osteoarthritis9

Obesity is an increasing problem in the population and also a significant risk factor for osteoarthritis. It is often associated with comorbidities such as diabetes, IHD, HT and sleep apnoea. Some years ago, an Arthritis Research Campaign Report 10 stated that joint surgery is less successful in obese patients because

Obese patients have a significantly higher risk of a range of short-term complications during and immediately after surgery (eg longer operations, excess blood loss requiring transfusions, DVT, wound complications including infection).

The heavier the patient, the less likely it is that surgery will bring about an improvement in symptoms (eg they are less likely to regain normal functioning or reduction in pain and stiffness)

The implant is likely to fail more quickly, requiring further surgery (eg within 7 years, obese patients are more than 10 times as likely to have an implant failure);

People who have joint replacement surgery because of obesity-related osteoarthritis are more likely to gain weight post-operatively (despite the new opportunity to lose weight through exercise following reduction in pain levels)

It also concluded that "Weight loss and exercise combined have been shown to achieve the same level of symptom relief as joint replacement surgery". A study of obese patients with knee osteoarthritis found that those who dropped their weight by 10% after a combination of diet and exercise reported less pain, better knee function, improved mobility and enhanced quality of life11.

A recent extensive literature review advises assessment of "timely weight loss as a part of conservative care"12. It confirms in detail the increased risk of many perioperative and postoperative complications associated with obesity (as well as increased costs and length of stay), such as wound healing/infections; respiratory problems; thromboembolic disease; dislocation; need for revision surgery; component malposition; and prosthesis loosening.

References

  1. RightCare Commissioning for Value Focus Pack for Vale of York CCG https://www.england.nhs.uk/resources/resources-for-ccgs/comm-for-value/north-region/#53
  2. NHS Vale of York Clinical Commissioning Group - Prevention and Better Health Strategy http://www.valeofyorkccg.nhs.uk/data/uploads/governing-body-papers/1-september-2016/item-7.1-prevention-and-better-health-strategy.pdf
  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. Optimising Outcomes from Elective Surgery Commissioning Statement Statement number: 01(link when PDF done)
  5. Obesity prevention NICE CG 43 Dec 2006; last amended March 2015 https://www.nice.org.uk/guidance/cg43
  6. RightCare Shared decision making tools
  7. NHS Choices: http://www.nhs.uk/chq/Pages/849.aspx?CategoryID=51&SubCategoryID=165
  8. Royal College of Surgeons Commissioning Guides: Painful osteoarthritis of the hip November 2013 http://www.rcseng.ac.uk/healthcare-bodies/docs/com...
  9. Royal College of Surgeons Commissioning Guides:Painful osteoarthritis of the knee November 2013 http://www.rcseng.ac.uk/healthcare-bodies/docs/commissioning-guides-boa/osteoarthritis-of-the-knee-final/view
  10. Arthritis Research Campaign: "Osteoarthritis and Obesity" (2009) http://www.arthritisresearchuk.org/external-resources/2012/09/17/15/29/osteoarthritis-and-obesity-a-report-by-the-arthritis-research-campaign.aspx
  11. Effects of intensive diet and exercise on knee joint loads, inflammation, and clinical outcomes among overweight and obese adults with knee osteoarthritis: the IDEA randomised controlled trial Messier et al JAMA 310(12) 1263-73 (2013) http://www.ncbi.nlm.nih.gov/pubmed/2406501
  12. Obesity and total joint arthroplasty: a literature based review. Journal of Arthroplasty May 2013 http://www.arthroplastyjournal.org/article/S0883-5403(13)00174-5/abstract

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: PA4 - 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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