General Commissioning Statement

Condition or Treatment / Knee Arthroscopy
Background / Recent evidence shows that arthroscopy for degenerative meniscal tears relating to OA of knee (with the exclusion of acute trauma, locked knee, ligament injury, and previous knee surgery) for patients 35 +, has no significant benefit 2 years post op over a physio led exercise program.
NICE CG 177 also recommends that:
‘Do not refer for arthroscopic lavage and debridement[3] as part of treatment for osteoarthritis, unless the person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, 'giving way' or X-ray evidence of loose bodies).’
This has led to the development of the following clinical threshold policy for knee arthroscopy.
Commissioning statement / Knee arthroscopy will only be commissioned for the following three scenarios in accordance with the criteria specified below:
1) Washout and debridement in Osteoarthritis
Unless there are documented mechanical features of locking which is associated with severe pain, arthroscopic debridement and washout is not routinely funded for chronic pain relief of osteoarthritis of the knee.
2) Diagnostic Arthroscopy
Unless one or more of the following criteria are met diagnostic arthroscopy of the knee is not routinely funded:
Significant knee pain having functional impact with diagnostic uncertainty following an MRI scan
OR
Suspected malignancy, infection, bony fracture or avascular necrosis
OR
Where MRI scan is not appropriate
3) Therapeutic Arthroscopy
Unless all of the following criteria are met, therapeutic arthroscopy of the knee is not routinely funded:
Clinical examination by a specialist or an MRI scan has demonstrated clear evidence of an internal joint derangement (meniscal tear, chondral flap, ligament rupture or loose body) with symptomatic and functional impairment
AND
Where conservative treatment has failed or where it is clear that conservative treatment will not be effective
This policy restriction does not apply where there is an urgent need for investigation/treatment.
Referral guidance / Cases which do not meet the critiera above and are deemed exceptional will need to be approved through the Individual Funding Request process
Effective from / October 2016
Summary of evidence /
Rationale / Marsh et al 2015, Cost-effectiveness analysis of arthroscopic Surgery compared to non-operative management for Osteoarthritis of the knee Marsh et al 2015Osteoarthritis and Cartilage 23 (2015) A26-A81
Thorlund et al 2015, Arthroscopic surgery for degenerative knee: systematic reviewand meta-analysis of benefits and harmsBMJ 2015;350:h2747
Kise et al 2016, Exercise therapy versus arthroscopic partial meniscectomy fordegenerative meniscal tear in middle aged patients: randomisedcontrolled trial with two year follow-upBMJ 2016;354:i3740
NICE CG 177 Osteoarthritis: Care and Management, February 2014
ESSKA Meniscus Consensus Project:Degenerative meniscus lesions

See Appendix 1 for ESSKA Meniscus Consensus algorithm.
Date / September 2016
Review Date / October 2017
Contact for this policy / Dr Bruce Willoughby
GP/Governing Member

Appendix 1: ESSKA Meniscus Consensus Algorithm