Surgical Threshold Policy

Transcription

1 Surgical Threshold Policy KNEE ARTHROSCOPY FOR CHRONIC KNEE PAIN Definition This policy only covers the use of knee arthroscopy as a surgical intervention or diagnostic tool for chronic knee pain. It does not cover arthroscopy recommended by an orthopaedic specialist in those under 18 years of age or in adults following acute injury with suspected internal joint derangement, septic arthritis or suspected malignancy. Policy It is the responsibility of referring and treating clinicians to ensure compliance with this policy. Referral proforma should be attached to the patient notes to aid the clinical audit process and provide evidence of compliance with the policy. For patients not meeting the policy criteria, clinicians can apply for funding to the Exceptional Cases Panel by completing the exceptional funding section of the referral proforma: Click policies to access the CCG clinical policies web page: policies select the Orthopaedic Surgery Policies drop down option and select the Knee Arthroscopy Policy to access the referral proforma. Primary/Community Care In patients with chronic knee pain, where evidence is provided that a comprehensive course of conservative treatment (lifestyle advice, optimum pharmacological treatments rest, self or physiotherapy guided mobilisation and strengthening exercises, intra-articular corticosteroids) has been tried for 12 months and failed, patients can be referred for specialist consultation. However, where patients have mechanical locking or symptoms that worsen with conservative treatment, these patients should be referred after shorter periods of conservative treatment. Referral for MRI scans should only be made by secondary care consultants or specialists working in CCG commissioned MSK services. Secondary Care Where a competent clinical examination or MRI scan has demonstrated clear evidence of a significant internal joint derangement which is likely to be the cause of the symptoms and suitable for treatment by knee arthroscopy, surgery will be funded. However, knee arthroscopy will not be funded for: 1. procedures that are not recommended by NICE, eg lavage; 2. procedures restricted by NICE, eg knee meniscus replacement with biodegradable scaffold, mosaicplasty, autologous chondrocyte implantation and trochleoplasty for patellar instability; 3. debridement, except in cases where there is mechanical locking; 4. use as a diagnostic tool, except in cases where there is on-going diagnostic uncertainty following both clinical examination and non-invasive imaging procedures (eg MRI) conducted by specialists. NOTE: Patients who smoke should be advised to attempt to stop smoking and referred to smoking cessation services. Patients who are overweight or obese should be offered referral to the appropriate weight management service. Page 1 of 5

2 Usual Pathway Patient presents with knee pain Chronic knee pain, eg due to age-related degeneration or exercise overuse injury GP advice Traumatic injury or septic arthritis Urgent referral Suspected malignancy Refer under 2 week wait No resolution Physiotherapy*/MSK referral Mechanical locking or worsening of symptoms with physiotherapy GP or MSK Referral to orthopaedic surgeon Further physiotherapy Where indicated, knee arthroscopy will be funded as detailed in the policy criteria above *Forms for physiotherapy referral available at: /en-us/default.aspx Rationale and Evidence Rationale for up to 12 months of conservative treatment in Chronic Knee Pain For patients with non-traumatic knee injury, evidence shows that, on average, conservative treatment is as effective as arthroscopic knee surgery for some procedures. Partial meniscectomy surgery showed no advantage over sham in one RCT of patients aged years with degenerative meniscal tears without osteoarthritis 1 and no advantage over physical therapy in two RCTs of older patients (>45 years) with osteoarthritis 2, 3. In 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 treatments 4. In an RCT of patients with patellarfemoral pain syndrome (18-40 years), mixed arthroscopic procedures and exercise resulted in equivalent improvements compared with exercise alone 5. Although rates of postoperative complications are generally low 6 higher rates have been observed in children and young people 7. There may also be future knee damage associated with arthroscopic procedures 8, 9 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 death 10. Page 2 of 5

3 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 equivalent 1. 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%) 2, 3 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 surgery 11. 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 unless part of a research study and prior approval for Excess Treatment Costs has been obtained. Further details on application for Excess Treatment costs are available on There is evidence that lavage does not improve patient outcome compared to sham and NICE does not recommend lavage 13. NICE recommends knee meniscus replacement with biodegradable scaffold only with special arrangements for clinical governance, consent and audit or research 17. NICE currently recommends that mosaicplasty should not be used without special arrangements for consent and audit or research 18. 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 studies 19. NICE recommends that arthroscopic trochleoplasty for patellar instability should only be used with special arrangements for clinical governance, consent and audit or research 20. There is some evidence that debridement is ineffective 12, 14, 15, but NICE recommends that debridement may be appropriate in cases where there is mechanical locking 12. Restricted use of MRI MRI is a good diagnostic tool 21, but may be inaccurate when used by less experienced staff 22 and its use is, therefore, restricted to secondary care or specialists working in CCG commissioned MSK services for this indication. Numbers of People Affected In Cambridgeshire and Peterborough, the estimated 2013/14 rate (and cost) of procedures associated with knee arthroscopy is 1,237 ( 2,552,637) per year, equating to approximately 0.12% of the local population. W82 W83 W84 W85 W87 Therapeutic endoscopic operations on semilunar cartilage. Therapeutic endoscopic operations on other articular cartilage. Therapeutic endoscopic operations on other joint structure. Therapeutic endoscopic operations on cavity of knee joint: W85.1 Removal of loose body W85.2 Endoscopic irrigation of knee joint W85.8 and W 85.9: other specified and unspecified Diagnostic endoscopic examination of the knee joint. Relevant OPCS codes References 1. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TLN 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: Katz J N, Brophy R H, Chaisson C E, de Chaves L P T, Cole B J, Dahm D L, Donnell-Fink L A, Guermazi A, Haas A K, Jones M H, Levy B A, Mandl L A, Martin S D, Marx R G, Miniaci A, Matava M J, Palmisano J, Reinke E K, Richardson B E, Rome B N, Safran-Norton C E, Skoniecki D J, Solomon D H, Smith M V, Spindler K P, Stuart M J, Wright J, Wright R W, Losina E. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. The New England Journal of Medicine 2013; 368(18): Page 3 of 5

4 3. Herrlin S V, Wange P O, Lapidus G, Hallander M, Werner S, Weidenhielm L. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc (2013) 21: 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 Kettunen J A, Harilainen A, Sandelin J, Schlenzka D, Hietaniemi K, Seitsalo S, Malmivaara A and Kujala U M. Knee arthroscopy and exercise versus exercise only for chronic patellofemoral pain syndrome: a randomized controlled trial. BMC Medicine 2007;5: Jameson S S, Dowen D, James P, Serrano-Pedraza I, Reed M R, Deehan D J. The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS. J Bone Joint Surg Br Oct;93(10): Ashraf A, Luo T D, Christophersen C, Hunter L R, Dahm D L, McIntosh A L. Acute and subacute complications of pediatric and adolescent knee arthroscopy. Arthroscopy Jun;30(6): 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): Piedade S R, Alban Pinaroli A, Servien E, Neyret P. Is previous knee arthroscopy related to worse results in primary total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc 2009; 17: 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:h Price A, Beard D. Arthroscopy for degenerate meniscal tears of the knee. BMJ 2014;348:g NICE Clinical Guideline 177. Osteoarthritis: Care and management in adults NICE Interventional Procedure Guidance 230. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. The Cochrane database of systematic reviews Health Quality Ontario. Arthroscopic lavage and debridement for osteoarthritis of the knee: an evidencebased analysis. Ontario health technology assessment series 2005;5(12): Reichenbach S, Rutjes A W S, Nüesch E, Trelle S, Jüni P. Joint lavage for osteoarthritis of the knee. The Cochrane database of systematic reviews NICE Interventional Procedure Guidance 430. Partial replacement of the meniscus of the knee using a biodegradable scaffold NICE Interventional Procedure Guidance 162. Mosaicplasty for knee cartilage defects NICE Technology Appraisal 89. The use of autologous chondrocyte implantation for the treatment of cartilage defects in knee joints NICE Interventional Procedure Guidance 474. Arthroscopic trochleoplasty for patellar instability Crawford R, Walley G, Bridgman S, Maffulli N. 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: Bryan S, Weatherburn G, Bungay H, Hatrick C, Salas C, Parry D, et al. The cost-effectiveness of magnetic resonance imaging for investigation of the knee joint. Health Technol Assess 2001;5(27):1-95. Arthroscopy: Articular cartilage: Autologous chondrocyte implantation: Chondroplasty: Debridement: Lateral release: Lavage: Ligament: Glossary Key-hole surgery using an arthroscope (light source and video camera). Tough, elastic, fibrous connective tissue. Harvesting of tissue from the edge of the affected knee joint which is cultured and, in a second surgical procedure, implanted into damaged areas. Type of trochleoplasty where a wedge of cartilage is cut, a small portion of bone beneath removed, and the cartilage is replaced (result is a deeper groove than trochleoplasty). Removal of dead, damaged, or infected tissue. Procedure used to loosen the tight tissue attached to the kneecap. Cleaning or rinsing. The fibrous tissue that connects bones to other bones. Page 4 of 5

5 Mosaicplasty: MRI: Trochleoplasty: Semilunar cartilage: Synovectomy: Glossary cont d Harvesting and transplanting many small cylindrical plugs of tissue from the less weight-bearing periphery and inserting them into drilled tunnels in the defective section of cartilage Magnetic resonance imaging. Deepening the groove or elevating the lateral wall of the trochlea. Any of the articular menisci of the knee joint. Surgery to remove inflamed joint tissue. Reviewed policy endorsed by CCG Governing Body 3 November 2015 Reviewed policy approved by SCPG on 30 September 2015 Reviewed policy approved by CPF on 8 September 2015 Policy adopted by CCG 1 April 2013 Policy effective from November 2015 Policy to be reviewed: November 2017 R:\CPF Pols & working Area\Surg Threshold Pols - Draft and Agreed\CCG Policies\ Reference: KNEE ARTHROSCOPY\V8 KNEE ARTHROSCOPY THRSHLD NOV 2015 Page 5 of 5