Orthopaedic knee procedures

Evidence

Systematic reviews make a recommendation against the use of arthroscopy in most patients with degenerative knee disease, knee pain or meniscal tear (1, 2, 3). 

The risks associated with arthroscopy include symptomatic deep vein thrombosis, pulmonary embolism, infection and death in the various studies that reported harms (2). 

NICE guidelines recommend that arthroscopic knee washouts alone should not be used as treatment for osteoarthritis as it doesn’t demonstrate any clinically useful short or long-term benefit (4). 

In addition, arthroscopic lavage and debridement should not be used in osteoarthritis without a clear history of mechanical locking (5).

Funding decision

This evidence appears to conclusively recommend against the use of arthroscopy in osteoarthritis and many meniscal tear procedures. Therefore, we’ll only routinely fund claims for arthroscopic procedures to manage loose bodies and chondral flaps where there are true mechanical symptoms (i.e. a locked knee or clear indications for synovial biopsies).

For other indications, we may ask you or your patients for more information to validate the indication for their procedure, to help us make a funding decision, or decline future claims.

Other information

We have seen a significant reduction in the number of knee arthroscopies performed since 2015. In cases of degenerative knee arthritis and meniscal tears, patients are likely to benefit more from conservative management over knee arthroscopy.

Evidence

Systematic reviews have shown no long-term significant improvement in patient-reported pain, wound scores and length of hospital stay those with osteoarthritis treated with PRP (6).

Individual research papers appear to be low-quality and non-randomised. One recent review found that despite some suggested early results of PRP injections and other therapies, many of these studies present with small sample sizes, inappropriate control cohorts and short-term follow-up (7).

NICE guidance agrees that there is limited evidence and further research is needed to validate PRP injections as a treatment (8).

Funding decision 

Currently, we don’t routinely fund claims for PRP injections in conditions where evidence does not support its use. This includes osteoarthritis and many tendinopathies.

We may, at our discretion, make exceptions if all of the following conditions are met. If this is the case please contact us to discuss further. 

• You’re currently providing PRP for the same indications in your NHS practice routinely
• You undertake a sufficient volume of PRP activity  
• You monitor and receive outcomes on all of your patients, and there’s evidence of your systems being effective
• You can demonstrate an adequate consent procedure which clearly documents and explains to members the evidence base and likelihood of benefit compared to other approaches.

Other information

Evidence

Similar to PRP injections, there doesn’t appear to be conclusive evidence of the benefit of ACI/MACI compared to more established treatments. We consider this treatment to be experimental and unproven at this stage (9, 10).

NICE guidelines recommend ACI as an option in very specific clinical scenarios, such as those patients who haven’t had previous surgery to repair articular cartilage defects, those with minimal osteoarthritic damage to the knee and if the defect is over 2cm2 (11). The guidance also mentions that it is unclear how well ACI works in the long term compared to micro fracture.

Funding decision

We don’t routinely fund claims for ACI/MACI, but may make an exception in certain circumstances where the procedure is carried out in accordance with NICE guidelines. Funding authorisation will be subject to receiving additional medical information to ensure the NICE guidance criteria is met.

Other information

According to our records, very few of our recognised consultants perform ACI/MACI procedures, for a small number of their patients, which is in line with the current evidence and guidance.

Evidence

NICE guidance states that intra-articular corticosteroid injections should be considered as an addition to core treatments for relief of moderate to severe pain in patients with osteoarthritis (11). There’s consistent evidence around the ability of intra-articular corticosteroid injections to provide short-term benefit (up to one week) in patients with osteoarthritis (12, 13).

NICE guidelines recommend not to undertake Hyaluronic acid injections.

Funding decision

We’ll fund one steroid injection per knee as a sole procedure per year. We won’t fund an injection when it’s carried out in conjunction with another therapeutic procedure where we expect this to be part and parcel of the treatment offered. We don’t fund hyaluronic acid injections or injections of other substances, in line with NICE guidance.

Other information

Knee injections are typically used in managing ongoing pain relief and depending on the cause of the condition, options may include physiotherapy or other surgical interventions.

Knee arthroscopy

1. Siemieniuk, R. A., Harris, I. A., Agoritsas, T., Poolman, R. W., Brignardello-Petersen, R., Van de Velde, S., & Helsingen, L. (2017). Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ, 357, j1982. 
2. Thorlund, J. B., Juhl, C. B., Roos, E. M., & Lohmander, L. S. (2015). Arthroscopic surgery for degenerative knee: systematic review and meta-analysis of benefits and harms. BMJ, 350, h2747.
3. Abram, S. G., Hopewell, S., Monk, A. P., Bayliss, L. E., Beard, D. J., & Price, A. J. (2019). Arthroscopic partial meniscectomy for meniscal tears of the knee: a systematic review and meta-analysis. British journal of sports medicine, bjsports-2018.
4. National Institute for Health and Care Excellence (2007). Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis. NICE Interventional procedures guidance. Retrieved from: nice.org.uk/guidance/ipg230
5. Kise N.J, Risberg M.A, Stensrud S, Ranstam J, Roos E.M (2016). Exercise therapy versus arthroscopic partial meniscectomy for degenerative meniscal tear in middle aged patients: randomised controlled trial with two year follow-up. BMJ, 354, i3740

Platelet-rich plasma injections in the knee
6. Muchedzi, T. A., & Roberts, S. B. (2018). A systematic review of the effects of platelet rich plasma on outcomes for patients with knee osteoarthritis and following total knee arthroplasty. The Surgeon, 16(4), 250-258.
7. Delanois, R. E., Etcheson, J. I., Sodhi, N., Henn III, R. F., Gwam, C. U., George, N. E., & Mont, M. A. (2018). Biologic therapies for the treatment of knee osteoarthritis. The Journal of arthroplasty.
8. National Institute for Health and Care Excellence (2007). Platelet-rich plasma injections for knee osteoarthritis. NICE Interventional procedures guidance. Retrieved from: nice.org.uk/guidance/ipg637

ACI/MACI 

9. Autologous Chondrocyte Implant (ACI). A Systematic Review. 
Galician Agency for Health Technology Assessment (AVALIA-T, 2009). Retrieved from: http://www.inahta.org/upload/Briefs_10/09160_AVALIA_Autologous_Chondrocyte_Implant_ACI_Systematic_Review.pdf 
10. Autologous Chondrocyte Implantation: Systematic Review. Künzl, M., Wild, C., Mathis, S., & Johansson, T. (2009). Retrieved from: http://eprints.hta.lbg.ac.at/865/
11. National Institute for Health and Care Excellence (2017). Autologous chondrocyte implantation for treating symptomatic articular cartilage defects of the knee. NICE Interventional procedures guidance. Retrieved from: nice.org.uk/guidance/ta477

Other knee injections
12. Jüni, P., Hari, R., Rutjes, A. W., Fischer, R., Silletta, M. G., Reichenbach, S., & da Costa, B. R. (2015). Intra‐articular corticosteroid for knee osteoarthritis. Cochrane Database of Systematic Reviews, (10). 
13. Glyn-Jones, S., Palmer, A. J. R., Agricola, R., Price, A. J., Vincent, T. L., Weinans, H., & Carr, A. J. (2015). Osteoarthritis. The Lancet, 386(9991), 376-387.