Our Guidelines To Orthopaedic Procedures For Knee Pain
The procedures listed below do not now meet the standards of evidence required for us to routinely fund them for our members. We are writing to all of our consultants to inform them of our latest funding guidelines and current evidence base.
In addition, we have written separately to consultants who are outliers to ask for further information on their practice. Where consultants are material outliers, or where there are unresolved concerns about the practice of individual consultants, we may consider concluding our commercial relationship with them. We are happy to report that the majority of our consultants do not perform these procedures.
To help our consultants to manage clinical effectiveness and improve our member care, we’ve included summaries of selected research and suggested alternatives.
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).
This evidence appears to conclusively recommend against the use of arthroscopy in osteoarthritis and meniscal tear procedures. Therefore, we’ll only routinely fund claims for 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 decline future claims or ask you or your patients for more information to validate the indication for their procedure to help us make a funding decision.
According to our records there’s been a significant reduction in the number of knee arthroscopies performed from 2015 to 2018. In cases of degenerative knee arthritis and meniscal tears, patients are found to benefit more from conservative management over knee arthroscopy. Most of our consultants recommend physiotherapy to members instead.
Platelet-Rich Plasma (PRP) Injections in the knee
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).
Research appear to be low-quality and non-randomised. One recent review found that despite some promising 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).
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.
Autologous Chondrocyte Implantation (ACI) and Matrix-Induced Chondrocyte Implantation (MACI)
Similar to PRP injections, there doesn’t appear to be conclusive evidence of the benefit of ACI/MACI compared to more established treatments, so it’s considered 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.
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 the above criteria. This is subject to receiving additional medical information to ensure the NICE guidance criteria is met.
According to our records, our consultant are currently performing a very low number of ACI/MACI procedures, which is in line with the current evidence and guidance.
Other knee injections
NICE guidance states that intra-articular corticosteroid infections should be considered as an addition to core treatments for relief of moderate to severe pain in patients with osteoarthritis (11). NICE guidelines recommend not to undertake Hyaluronic acid injections.
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).
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.
Knee injections are typically an addition in managing ongoing pain relief and depending on the cause of the condition, options may include physiotherapy or more definitive surgical intervention.
Got a question?We understand that there are certain clinical scenarios, as well as variation in opinion, where these orthopaedic procedures may be recommended. So, if you are in any doubt, please contact us BEFORE you recommend the procedure and we’ll do all we can to find an acceptable solution for you and our member.
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
9. Autologous Chondorcyte Implant (ACI). A Systematic Review.
Galacian 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.