Osteoarthritic Knee Pain Commissioned Pathway

Scope

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.

Out of Scope

  • Knee pain for reasons other than osteoarthritis: see Knee Pain other
  • DRSS will review the referral letter and direct to Orthopaedics if:
    • Under 16 years of age
    • Arthroscopy recommended by an orthopaedic specialist in those under 18 years of age
    • Recent surgery same joint less than six month ago
    • Metal work in situ in the area
    • Previous arthroplasty same joint/joint replacement
    • Inflammatory Arthritis
    • Suspected serious pathology (see Red Flags)
    • Leaking wound/possible infections
    • Acute or recent locked knee (of note, referral letter should mention locking knee to enable screening)
    • Meniscal cysts

Key messages

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.

Assessment

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

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

Investigations

**ADDENDUM 24/5/21 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **

Knee X-ray (standing AP and lateral) reports should ideally 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.

Management

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:

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:

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

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. **ADDENDUM 24/5/21 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **

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

Referral Instructions

For Knee select:

Priority:Routine/ Urgent

Specialty: Orthopaedics

Clinic type: Knee

Service: DRSS-Northern-Orthopaedics-Knee- Devon CCG- 15N

Referral Forms

DRSS referral form

Supporting Information

GP Information

Shared decision making – osteoarthritis of the knee

Patient Information

MyHealth patient information - Knee Pain (Osteoarthritis)

PALS information leaflet

Patient transport services

Pathway Group

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

Publication date: July 2020

Updated: June 2021

Last updated: 24-06-2021

 

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