Signs and Symptoms

• Age
• Onset of pain or swelling
• Anatomical location, character and severity of pain
• Previous episodes, other knee conditions or past knee surgery
• Other joint problems (in particular the hip and lower back)
• Other medical and drug history and general systemic health

Red Flags which will bypass the Community Assessment Service (should be referred urgently to secondary care)

• Fracture or trauma
• Suspicion of tumour or evidence of any destructive lesion on radiograph
• Unexplained, increasing or sudden onset severe pain in a previously replaced joint
• Any features suspicious of infection, including:
  • Cellulitis over the joint
  • Large effusion and erythema
  • Inflamed scar/wound over a previously replaced joint
• Inability to walk or weight bear
• Evidence of new inflammatory arthropathy
• Avascular necrosis/osteonecrosis

Knee X-ray (standing AP and lateral) reports must accompany all knee referrals in all those over 55 years of age (independent of suspected aetiology) or younger when OA is suspected.

The clinical indications for this are:

1) to rule OA in or out as a differential for the patient's symptoms

2) to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g., avascular necrosis (an indication for expedited referral).

3) deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up-to-date X-ray is extremely useful for remote/virtual consultations.

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient’s symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.

Please ensure that the X-ray report is attached to avoid unnecessary delay.

It is the responsibility of the referrer to attach the report.

In proven Osteoarthritis

• Arthroscopy and washout are not indicated for knee osteoarthritis unless there are true mechanical instability symptoms
• Steroid joint injection should be considered. If there is no response, then other management options should be discussed.

Please be aware that injection can cause chondrolysis or infection and should not be performed if joint replacement is anticipated in the next 6 months

Arthroplasty should only be considered if:

• Function restriction resulting from significant or progressive deformity and instability of knee may be most important indication
• Moderate to severe pain
• Moderate to severe joint pathology identified by X-ray
• Failed conservative measures, when appropriate Chapter 10 - Musculoskeletal & joint diseases
• Patient willing and fit for surgery - Shared decision making – osteoarthritis of the knee

Other impaired quality of life factors, e.g. loss of independence, depression (in the case of the latter – have they tried CBT which can help chronic pain)

For any patient where surgical intervention is being considered then the fitness for surgery needs to be addressed:

• Lifestyle advice (including weight management and smoking cessation)
  • Mild Symptoms
  • Offer verbal and written information about condition
  • Offer information to support weight loss if people are overweight or obese (BMI greater than 30) as a core treatment
  • Advise on local muscle strengthening and general aerobic exercise as a core treatment
  • Use of shared decision-making tools
  • Suggest OTC oral simple analgesia and anti-inflammatory medication
  • Assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid
  • Prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate Symptoms:

• As above, and
• Consider prescription analgesia and NSAIDs - Joint Formulary Chapter 10.1

Unless red flags are present all patients referred for consideration of arthroplasty due to knee osteoarthritis will be assessed by a community assessment service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford knee scoring and patient decision-making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well-being or surgery.

Contraindications to knee arthroplasty

Absolute:

• Current infection of knee
• Other site of infection
• Muscular dysfunction
• Severe peripheral vascular disease
• Presence of functional knee arthrodesis

Relative:

• History of osteomyelitis
• Skin conditions around knee
• Neuropathy of knee joint
• Obesity

Referral Criteria

Referral to specialist secondary care:

All referrals should include:

• History and duration
• Presence and time of onset of any swelling
• Instability symptoms or history of overuse
• Relevant examination findings
• Relevant investigations

All referrals must include:

1. Details of persistent pain or disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. Please include details (including dates) of conservative treatment (e.g. analgesia, steroid joint injection)
2. A recent course of physiotherapy will be expected unless this is not clinically appropriate (within the twelve months prior to referral). This clinical decision needs to be stated and if it is not then the referral will be returned.
3. Knee X-ray (standing AP and lateral) reports must accompany all knee referrals in all those over 55 years of age (independent of suspected aetiology) or younger when OA is suspected.
   

The clinical indications for this are:

1. to rule OA in or out as a differential for the patient's symptoms
2. to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g. avascular necrosis (an indication for expedited referral).
3. deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up to date X-ray is essential to facilitate remote/virtual consultations

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient's symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.

Please ensure that the X-ray report is attached to avoid unnecessary delay.

It is the responsibility of the referrer to attach the report.

Please note primary care is encouraged to follow In Shape for Surgery best practice which can be seen here.

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Referral Instructions

For Knee select:

Priority: Routine/ Urgent

Specialty: Orthopaedics

Clinic type: Knee

Service: DRSS-Eastern-Orthopaedics-Knee- Devon ICB- 15N

Fast Track Knee Referral Assessment Service select.

Priority: Urgent

Speciality: Orthopaedics

Clinic Type: Knee

Service: Fast Track Knee Referral Assessment Service-Orthopaedic Department-RDE-RH8 7932867

• The fast track knee service is only for young active patients who have sustained recent trauma that may benefit from early surgery. Older patients with no significant injury/trauma are not suitable for the Fast Track Knee service and should be directed to conservative management.

Referral Form

DRSS Referral Form

GP Information

Shared decision making – osteoarthritis of the knee

Patient Information

MyHealth patient information - Knee Pain (Osteoarthritis)

Patient transport services

Pathway Group

This guideline has been signed off on behalf of the NHS Devon.

Publication date: July 2020

Updated: December 2023