LOW PRIORITY PROCEDURE Policy TXX Knee Arthroscopy

Policy author: Policy start date: Review date: NHS Suffolk Public Health Team November 2011 November 2013

Policy Summary Knee arthroscopy is considered to be a low priority treatment and will only be funded by NHS Suffolk in line with the criteria below. As primary care clinicians do not normally refer specifically for knee arthroscopy, this threshold policy predominately applies to secondary care clinicians. Treatment criteria Knee arthroscopy can be undertaken where a competent clinical examination (or MRI scan) has demonstrated clear evidence of internal joint derangement and where conservative treatment has failed or where it is clear that conservative treatment will not be effective. Arthroscopy should not be considered a diagnostic tool except where there is continuing diagnostic uncertainty despite non-invasive investigations. NHS Suffolk will fund knee arthroscopy for the following clinical indications: Diagnostic arthroscopy: On-going diagnostic uncertainty despite competent clinical examination and noninvasive investigations (MRI) Therapeutic arthroscopy: Removal of a loose body Meniscal surgery (repair or resection) Ligament reconstruction/repair (including lateral release) Synovectomy Evidence of knee osteoarthritis with a clear history of mechanical locking ( not gelling, giving way, or X-ray evidence of loose bodies) Background to the condition and treatment Knee arthroscopy involves inserting a camera into the knee joint via small incisions to enable the internal structure of the knee to be examined 1, and this can be diagnostic and/or therapeutic. Many of these procedures can be done as day cases, and a general anaesthetic is not always necessary. In addition, there is less tissue trauma, less pain, lower morbidity and it has quicker recovery times that more invasive surgery 2. Common situations for it to be considered in include removal of loose bodies, repair of meniscal tears, ligament reconstruction or repair, biopsies or synovectomy 3. Arthroscopy is generally a safe procedure with a low risk of complications. Possible post-operative complications include neurovascular injury, post operative pain, haemarthrosis, thromboembolism and infection4.

Rationale behind the policy decision Therapeutic Arthroscopy Arthroscopic lavage with or without debridement is often used for knee osteoarthritis when medical management fails to control the symptoms. However, it is unclear as to why this intervention offers symptomatic relief. Multiple studies have investigated the impact of arthroscopy on pain and functional levels and in 2007 NICE issued guidance 5-6 which states that referral for arthroscopic lavage and debridement should not be offered as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (not gelling, 'giving way' or X-ray evidence of loose bodies). Since this was published there has been one further RCT 7 which compared pain and functional scores between patients who have arthroscopic lavage and debridement alongside physical and medical therapy, with those who had physical and medical therapy alone. The results showed no statistically significant difference between the pain and functional scores of the two groups over a two year follow up period. A systematic review published in 2008 analysed three RCTs and concluded that there was strong evidence that arthroscopy had no significant impact on patients pain and functional scores8. These papers support the NICE guidance that there is limited evidence as to the long term benefits of knee arthroscopy in osteoarthritis and therefore it should not be offered as part of the treatment for osteoarthritis except in cases of mechanical locking. Diagnostic Arthroscopy Arthroscopy has, in the past, been used as an effective diagnostic tool for knee disorders and it offers the advantage of being accurate and enabling treatment at the same time as diagnosis. However some studies have promoted the use of MRI as a primary diagnostic tool as it is non-invasive, safer and less expensive than arthroscopy. Recent studies have produced conflicting evidence as to how MRI should be used in this area. One RCT 9 in 2004 suggested that it is cost-neutral to perform MRI in all patients who are being considered for arthroscopy since the cost saved from the minority of patients who subsequently avoid arthroscopy covers the cost for the majority to have MRI. However a similar RCT10 in 2007 showed no reduction in the number of arthroscopies done after MRI and noted that although MRI did change the diagnosis in 47% of cases this change did not impact the need for subsequent arthroscopy. Adding to this evidence are two prospective cohort studies, one of which demonstrated MRI to be a sensitive and specific diagnostic tool for knee disorders 11 and the other showed MRI to be no better at predicting the final diagnosis than a competent clinical examination 12. The evidence available supports MRI as an accurate cost-effective alternate to diagnostic arthroscopy however there may be no advantage of performing MRI in patients who have clear evidence of internal joint derangement demonstrated on clinical examination. Although more research is needed in this area, the evidence suggests that MRI should be reserved for situations of diagnostic uncertainty and that diagnostic arthroscopy is only indicated after an MRI has been performed if on-going uncertainty exists. It should be noted that MRI is always indicated in the presence of red flag symptoms/signs/conditions*. *Red flag symptoms or signs include recent trauma, constant progressive nonmechanical pain (particularly at night), previous history of cancer, long term oral steroid use, history of drug abuser HIV, fever, being systematically unwell, recent unexplained weight loss, persistent severe restriction of joint movement, widespread neurological changes, and structural deformity. Reflag conditions include infection, carcinoma, nerve root impingement, bony fracture and avascular necrosis.

References 1. http://www.medicinenet.com/arthroscopy/article.htm (accessed 06/09/11) 2. Onyema C, Oragui E, White J, Khan W. Evidence-based practice in arthroscopic knee surgery. Journal of perioperative practice 2011; 21(4): 128-34 3. Villar RN. Minimally Invasive Surgery: Arthroscopy. British Medical Journal 1994l; 308: 51 4. Allum R. Complications of arthroscopy of the knee. Journal of Bone and Joint Surgery 2002; 84(7): 937 5. NICE. IPG230 Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis. National Institute for Health and Clinical Excellence Interventional Procedures Programme, August 2007. 6. NICE CG59 Osteoarthritis: the care and management of osteoarthritis in adults. National Institute for Health and Clinical Excellence (NICE), Feb 2008. 7. Kirkley A et al. A Randomized Trial of Arthroscopic Surgery for Osteoarthritis of the Knee. The New England Journal of Medicine. 2008 Sep 11;359(11):1097-107 8. Laupattarakasem W, Laopaiboon M and Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database of Systematic Reviews 2008, Issue 1. Art. No.:CD005118. 9. Brian S, Bungay HP, Weatherburn G and Field S. Magnetic resonance imaging for investigation of the knee joint: a clinical and economic evaluation (Structured abstract). International Journal of Technology Assessment in Health Care , 2004; 20: 222-229. 10. Bridgman et al. The Effect of Magnetic Resonance Imaging Scans on Knee Arthroscopy: Randomized Controlled Trial. The Journal of Arthroscopic and Related Surgery, Vol 23, No 11, 2007: pp1167-1173 11. Vincken PW et al. Effectiveness of MR Imaging in Selection of Patients for Arthroscopy of the Knee. Radiology. 2002 Jun;223(3):739-46 12. Brooks S, Morgan M. Accuracy of clinical diagnosis in knee arthroscopy. Annals of the Royal College of Surgeons of England, 2002; 84: 265-268

Appendix Relevant OPCS Codes: W82 - Therapeutic endoscopic operations on semilunar cartilage, all sub codes are within guidance. W83 - Therapeutic endoscopic operations on other articular cartilage, all sub codes are within guidance. W84 - Therapeutic endoscopic operations on other joint structure, all sub codes are within guidance. W85 - Therapeutic endoscopic operations on cavity of knee joint: - W85.1 Removal of loose body is within guidance. - W85.2 Endoscopic irrigation of knee joint (includes lavage and washout of knee joint) is outside of guidance, i.e. likely not to be appropriate needs to be referred to Individual Funding Request Panel. W87 - Diagnostic endoscopic examination of the knee joint outside of guidance i.e. likely not to be appropriate needs to be referred to Individual Funding Request Panel.