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Knee arthroscopy for patients with osteoarthritis

Knee arthroscopy for patients with osteoarthritis

Statutory Guidance

How up to date is this Information?

Published January 2019 | Last reviewed September 2024

Using this guidance

The guidance set out here was reviewed extensively in the Autumn of 2024. There are no plans for any further reviews.

Medicine is constantly evolving and over time it is inevitable that the evidence base will change. Please use your own judgement and/or other sources of clinical guidance alongside the information set out here.

Please note this guidance is a recommendation and it should be used in the context of the overall care pathway and when all alternative interventions that may be available locally have been undertaken.

Summary

Arthroscopic washout of the knee is an operation where an arthroscope (camera) is inserted into the knee along with fluid. Occasionally loose debris drains out with the fluid, or debridement, (surgical removal of damaged cartilage) is performed, but the procedure does not improve symptoms or function of the knee joint.

Recommendation

Arthroscopic knee washout (lavage and debridement) should not be used as a treatment for osteoarthritis because it is clinically ineffective.

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.

More effective treatment includes exercise programmes (e.g. ESCAPE pain), losing weight (if necessary) and managing pain. Osteoarthritis is relatively common in older age groups. Where symptoms do not resolve after non- operative treatment, referral for consideration of knee replacement, or joint preserving surgery such as osteotomy is appropriate.

For further information, please see:

  • NICE Interventional procedure overview of arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis [IP366]
  • NICE Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis [IPG230]
  • NICE Do not do recommendations
  • Escape Pain

Rationale for recommendation

NICE has reviewed the evidence for how well knee washout works for people with osteoarthritis. Seven clinical trials and three case studies have shown that knee wash out for people with osteoarthritis did not reduce pain nor improve how well their knees worked. There was a small increased risk of bleeding inside the knee joint (haemarthrosis) (2%) or blood clot in the leg (deep vein thrombosis) (0.5%).

Patient information

Information for Patients

Surgery to washout and remove debris to relieve knee pain (a knee arthroscopy) is a procedure that should only be carried out when specific criteria are met. This is because the medical evidence tells us that the intervention can sometimes do more harm than good and there are alternative treatments which are usually far more effective. However, a knee arthroscopy can considered if you have arthritis in your knee, or other specific symptoms such as locking of the knee. It can also be carried out if doctors need to assess your suitability for other procedures.

About the condition

Osteoarthritis is a common condition affecting nearly 9 million people in the UK. It initially affects the smooth cartilage lining of the joint and makes movement more difficult, leading to pain and stiffness. Once the cartilage lining starts to roughen and thin out, the tendons and ligaments have to work harder. This can cause swelling and the formation of bony spurs, called osteophytes. Severe loss of cartilage can lead to bone rubbing on bone, altering the shape of the joint and forcing the bones out of their normal position.

It’s important you and the doctor or the specialist clinician treating you make a shared decision about what’s best for you if your knee pain is becoming a problem. When deciding what’s best you should both consider the benefits, the risks, the alternatives and what will happen if you do nothing.

What are the BENEFITS of the intervention?

Arthroscopy for osteoarthritis in the knee will only benefit you if there is a history of specific symptoms such as the knee locking.

What are the RISKS?

The risks of arthroscopy include infection, bleeding and pain as well the risks of the anaesthetic for the procedure. There is also an increased risk of blood clots in the leg following the procedure.

What are the ALTERNATIVES?

There are a number of alternatives that can improve symptoms and function. These include, exercise, physiotherapy, losing weight and sometimes steroid injections. Carefully managed pain relief for relatively short periods can also be prescribed.

What if you do NOTHING?

Doing nothing is not likely to be harmful. Arthritis can be painful and affect your mobility. The less invasive options should always be considered first with knee replacement surgery only being considered as a last resort when other treatment options have been shown not to work.

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2019

Make the most of your appointment using BRAN

2020

Coding

WHEN (Primary_Spell_Procedure IN ('W851','W852')
OR (Primary_Spell_Procedure = 'W802' AND 
(Any_Spell_Procedure like '%Y767%' 
AND Any_Spell_Procedure like '%Z846%' )))
AND ( Primary_Spell_Diagnosis like 'M17[0123459]%' 
OR Primary_Spell_Diagnosis like 'M15[0123489]%')
AND Any_Spell_Procedure not like '%M238%'
-- Age Between 19 and 120
AND ISNULL(APCS.Age_At_Start_of_Spell_SUS,APCS.Der_Age_at_CDS_Activity_Date) between 19 AND 120 
-- Only Elective Activity
AND APCS.Admission_Method not like ('2%')
THEN 'C_knee_arth'
Exclusions
WHERE 1=1
-- Cancer Diagnosis Exclusion
AND (Any_Spell_Diagnosis not like '%C[0-9][0-9]%' 
AND Any_Spell_Diagnosis not like '%D0%' 
AND Any_Spell_Diagnosis not like '%D3[789]%' 
AND Any_Spell_Diagnosis not like '%D4[012345678]%' 
OR Any_Spell_Diagnosis IS NULL)
-- Private Appointment Exclusion
AND apcs.Administrative_Category<>'02'

References

  1. NICE interventional procedures guidance (2006) Interventional procedures programme: Interventional procedure overview of arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis [IP366]
  2. NICE interventional procedures guidance (2007) Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis [IPG230]
  3. British Orthopaedic Association and the Royal College of Surgeons (2017) Commissioning Guide: Painful Osteoarthritis of the knee.
  4. Siemieniuk Reed A C, Harris Ian A, Agoritsas Thomas, Poolman Rudolf W, Brignardello-Petersen Romina, Van de Velde Stijn et al. arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline BMJ 2017; 357 :j1982
  5. Brignardello-Petersen R, Guyatt GH, Buchbinder R, et al Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review BMJ Open 2017;7:e016114. doi: 1136/bmjopen-2017-016114`
  6. Moseley JB, O’Malley K, Petersen NJ et al. (2002) A controlled trial of arthroscopic surgery for osteoarthritis of the knee. The New England Journal of Medicine 347: 81–8.
  7. Hubbard MJS. (1996) Articular debridement versus washout for degeneration of the medial femoral condyle. Journal of Bone and Joint Surgery (British) 78-B: 217–19.
  8. Kalunian KC, Moreland LW, Klashman DJ et al. (2000) Visually- guided irrigation in patients with early knee osteoarthritis: a multicentre randomized controlled trial. Osteoarthritis and Cartilage 8: 412–18.
  9. Chang RW, Falconer J, Stulberg SD et al. (1993) A randomized, controlled trial of arthroscopic surgery versus closed-needle joint lavage for patients with osteoarthritis of the knee. Arthritis & Rheumatism 36: 289–96.
  10. Forster MC, Straw R. (2003) A prospective randomised trial comparing intra-articular Hyalgan injection and arthroscopic washout for knee The Knee 10: 291–3.
  11. Jackson RW, Dieterichs C. (2003) The results of arthroscopic lavage and debridement of osteoarthritic knees based on the severity of degeneration: a 4- to 6-year symptomatic follow-up. Arthroscopy: The Journal of Arthroscopic and Related Surgery 19: 13–20.
  12. Bernard J, Lemon M, Patterson MH. (2004) Arthroscopic washout of the knee – a 5-year survival The Knee 11: 233–5.
  13. Harwin (1999) Arthroscopic debridement for osteoarthritis of the knee: predictors of patient satisfaction. Arthroscopy: The Journal of Arthroscopic and Related Surgery 15: 142–6.
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