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This clinical referral guideline (commissioned pathway) covers referrals for knee pain due to osteoarthritis, including elective knee replacement to replace some or all the components of the knee joint with a synthetic implant, and repair damaged weight bearing surfaces.
Conservative management is the main stay of treatment; rest, analgesia and primary care physiotherapy.
Hip pathology can present with pain in the knee only
Because of the lack of evidence around long term benefits, arthroscopy and washout for global knee pain due to osteoarthritis is considered a low value procedure and referrals for arthroscopy will be returned.
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.
MRI requests can be made by the Extended Scope Physiotherapist (ESP) or Integrated Clinical Assessment and Treatment (ICAT) clinician; GP's are no longer able to order MRI through the Any Qualified Provider (AQP) process.
Red Flags which will bypass the Community Assessment Service (should be referred urgently to secondary care)
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
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:
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:
Moderate Symptoms:
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:
Relative:
Referral to specialist secondary care:
All referrals should include:
All referrals must include:
The clinical indications for this are:
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.
For Knee select:
Priority: Routine/ Urgent
Specialty: Orthopaedics
Clinic type: Knee
Service: DRSS-Northern-Orthopaedics-Knee- Devon ICB- 15N
Shared decision making – osteoarthritis of the knee
MyHealth patient information - Knee Pain (Osteoarthritis)
This guideline has been signed off on behalf of the NHS Devon.
Publication date: July 2020
Updated: December 2023