Knee Osteoarthritis - Adult Leeds

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1.  Information Resources for Patients and Carers

Quick info:
Patient information

information leaflet for Joint/Joint Line Pain (Meniscal Tear, Ligament Injury, Cartilage Injury)

Information leaflet Osteoarthritis of Knee

Decision Aid Knee Replacement

patient information leaflet for knee replacement surgery from Arthritis Research UK.
Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

information leaflet for anterior knee pain

information leaflet for patella tendinopathy

patient information leaflet for Baker's Cyst

information leaflet for bursitis of the knee.

information leaflet for patellofemoral pain

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2.  Referral Forms

Quick info:
Referral Forms

Quick View - PDF
MSK4 Knee Form V3
MSK5 Knee Replacement Triage Form V3
MSK 6 Acute Severe Knee Injury Form V3
MSK14 Problem not on Pathway Form V3

Mail Merged
The forms below are provided as a repository. They can be downloaded to your computer and be imported to your clinical system. This is so all practices have access to the most up to date forms.

EMIS - merged
MSK4 Knee Form V3
MSK5 Knee Replacement Triage Form V3
MSK 6 Acute Severe Knee Injury Form V3
MSK14 Problem not on Pathway Form V3

SystmOne - merged
MSK4 Knee Form V3
MSK5 Knee Replacement Triage Form V3
MSK 6 Acute Severe Knee Injury Form V3
MSK14 Problem not on Pathway Form V3

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3.  Suspected Knee Osteoarthritis Assess Pain / Function

Quick info:
Guidance will be provided as part of the IT practice software supporting the referral management process, including scoring criteria for pain/functional impairment.

GP Information
Knee osteoarthritis is common and may affect anyone. The knee cartilage becomes thin and rough, with the underlying bone growing thicker and broader. Osteophytes are formed, and an effusion may develop from the inflammatory response to the changes with the joint (synovitis).

Those at increased risk include:

  • older age-groups
  • female
  • family history
  • overweight
  • previous joint surgery/injury, eg meniscectomy
  • other joint condition, eg rheumatoid disease, gout, etc
  • certain occupations

The patient with knee osteoarthritis may report:

  • pain (typically worse at the end of the day, or with activity)
  • stiffness with rest that improves within minutes of activity
  • cracking, crunching, grinding etc of the knee with movement
  • swelling
  • knee giving way
  • loss of movement of the knee

On examination, findings may include:

  • joint line tenderness
  • crepitus with patella movement
  • quadriceps muscle bulk wasting
  • flexion, varus or valgus deformity

When osteoarthritis is suspected, an assessment of severity should be made on the basis of the signs and symptoms. The following factors should be taken into account:

  • Pain:
    • What analgesia has the patient tried so far? (see 'Home management' node for advice on pain management)
    • Is the patient on maximum tolerated analgesia?
    • Is the patient kept awake at night with pain?
  • Function:
    • Is the patient able to perform activities of daily living?
    • How far can the patient walk?
    • Are walking aid required?
    • Does the knee persistently give way?
  • Examination:
    • Is there significant loss of quadriceps muscle bulk?
    • Is there a fixed flexion/ varus / valgus deformity?

If there is only mild intermittent pain (settling with analgesia), with no functional disruption and a relatively normal examination there is no need to obtain radiographs at this stage. It would be appropriate to follow the ‘Not severe’ pathway and provide the advice on the ‘Home management’ node.

If symptoms are deemed severe (significant pain, disruption of function, positive examination findings), a weight bearing X-ray AP and Lateral should be obtained to assess for the presence and severity of Tibiofemoral osteoarthritis (see ‘Assess Tibiofemoral Osteoarthritis Severity’ node for further information).

It is worth mentioning here that NICE CG59 states ‘Intra-articular corticosteroid injections should be considered as an adjunct to core treatment for the relief of moderate to severe pain in people with osteoarthritis’. This may be provided in-house if expertise exists and may be useful for those patients who decline or are unsuitable for surgery but report significant pain.

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6.  Home Management

Quick info:
Patient information
Please see information leaflet Osteoarthritis of Knee on information and exercises for management of osteoarthritis.

GP information
When osteoarthritis is suspected but symptoms are mild, a period of conservative management is likely indicated. Advice to patients may include:

  • Appropriate analgesia:
    • NICE CG59 recommends step-wise approach:
      • Paracetamol +/- topical NSAID
      • Opioid analgesia / oral NSAID (may need concurrent PPI) only if the above is insufficient after risk/ benefit consideration
      • Topical capsaicin may be considered for OA knee
  • Non-pharmacological therapies:
    • Application of heat or cold to site of pain
    • TENS machine (patient would need to purchase)
  • Weight management
  • Exercise:
    • Advise regular short duration low impact activity
    • Advise regular aerobic exercise, eg swimming
    • Advise specific muscle group strengthening exercises (these are described on the attached patient information leaflet)
  • Activity modification/Knee-strain reduction:
    • Simple advice may include pacing activity throughout the day, and the use of low heeled shoes with thick soft soles.
  • Alternative therapies:
    • There is no convincing evidence for these. Patients who consult alternative practitioners should ensure they are registered with the appropriate regulatory organisation.
    • Glucosamine is not recommended by NICE. Acupuncture has a limited evidence-base for OA knee but is not recommended by NICE.

Patients should be provided with the attached information leaflet on osteoarthritis of the knee.

If symptoms persist then obtaining a weight bearing AP and lateral knee X-Ray is appropriate to assess severity. Further management is then outlined on the pathway according to the X-Ray results and severity of symptoms.

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8.  X-Ray Shows Mild or No Osteoarthritis

Quick info:
GP Information
If patients only have mild OA changes or normal X-ray but have significant pain, then diagnostic uncertainty exists and hence the need to refer to the MSK-MDT.

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10. Refer to MSK-MDT Form (MSK4)

Quick info:
Referral Form:
MSK4 Knee Form V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality:Orthopaedics
Clinic Type: Knee

Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

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13. Web Based Patient Decision Aid

Quick info:
Patient information
Decision Aid Knee Replacement

GP information
The link above to the NHS / BMJ Group Shared Decision Making website may assist when discussing with patients whether or not a referral for hip replacement is appropriate.

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15. Refer to Tier 1 Physiotherapy Form (MSK4)

Quick info:
Referral Form:
MSK4 Knee Form V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Physiotherapy
Clinic Type:Musculoskeletal

Provider information
The only provider of Tier 1 physiotherapy in the city is the Leeds Musculoskeletal Service. This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

If symptoms persist, referral to Tier 1 physiotherapy is appropriate, who will refer onward to MSK-MDT if symptoms persist or there is diagnostic doubt.

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16. If BMI  ≥   35

Quick info:
Knee Replacement Patient Information Leaflet

Patient Information Leaflet Surgery BMI over 35

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17. BMI < 35 Patient Willing / Suitable for Surgery

Quick info:
Patient information

Decision Aid Knee Replacement

Knee Replacement Patient Information Leaflet

Patient Information Leaflet Surgery BMI over 35

As part of the counselling GPs provide to patients before referral for probable knee replacement, it is important that the patient receives written information.

It is good practice to give patients time to read and consider this information.

Please see the attached comprehensive patient information leaflet on knee replacement surgery from Arthritis Research UK. The hope is to improve the informed consent process and reduce referrals to orthopaedic surgeons that end with the patient declining surgery after they become aware of what is involved.

GP information
In addition to the normal pre-operative discussion concerning relative risks/benefits, recovery time, likely outcome etc, willing/able to undergo surgery will include a threshold that patients with a BMI>35 should not routinely be offered surgery (exceptions can still be considered through the exceptions panel in the normal way).

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19. Refer to MSK-MDT Form (MSK4)

Quick info:
Referral Form:
MSK4 Knee Form V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Orthopaedics
Clinic Type: Knee

Provider information
The only provider of the MSK-MDT clinic in the city is the Leeds Musculoskeletal Service. This is a multiprofessional clinic including senior physiotherapists and musculoskeletal physicians.

This clinic provides diagnosis, investigation, treatment and onward referral if needed.

This service is directly bookable via Choose and Book. Please complete the appropriate form and send via Choose and Book.

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20. Age < 65 years

Quick info:
GP information

For patients < 65 years of age with a BMI > 35 meeting the criteria for knee replacement surgery, a weight loss target over a set period of time (months) should be agreed with the patient before considering referral for knee replacement.

This can be individualised between the GP and the patient, and may (but does not have to) include referral to a weight management service. The rationale for this includes an increased failure rate and complication rate associated with hip replacement procedures in those with high BMI's.

If the individualised agreed weight loss target is achieved then referral to MSK-MDT Triage for a knee replacement is indicated. If the weight loss target is not achieved then the increased failure rate and complication rate associated with knee replacement procedures in those with high BMI' s should be discussed with the patient. The patient should be provided with the information leaflet explaining these issues.

If the patient is fully informed, accepts the potential risks and remains keen to be referred for knee replacement surgery then referral to MSK-MDT Triage is indicated. Please do not refer patients who are undecided and may not wish to proceed with surgery.

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21. Age  ≥  65 years

Quick info:
GP information

For patients ≥  65 years of age with a BMI ≥  35 meeting the criteria for knee replacement surgery, it has been agreed locally that weight loss targets may be unrealistic.

The increased failure rate and complication rate associated with knee replacement procedures in those with high BMI' s should be discussed with the patient. The patient should be provided with the information leaflet explaining these issues.

If the patient is fully informed, accepts the potential risks and remains keen to be referred for knee replacement surgery then referral to MSK-MDT Triage is indicated. Please do not refer patients who are undecided and may not wish to proceed with surgery.

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23. Agree Weight Loss Goal

Quick info:
Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

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25. Goal Achieved

Quick info:
Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

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26. Goal Not Achieved

Quick info:

Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

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27. Provide Pre-Op Knee Replacement Patient Information Leaflet

Quick info:
Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

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28. Provide High BMI Pre-Op Knee Replacement Patient Information Leaflet

Quick info:
GP Information

Patient Information Leaflet Surgery BMI over 35

Knee Replacement Patient Information Leaflet

For patients who have tried and failed to get their BMI below 35, but you feel would clearly benefit from a knee replacement as long as they are accepting of the increased surgical risk and potential reduced success of the procedure, then referral for surgery is appropriate.

Patients who are 65 years or older and have a high BMI should be encouraged to lose weight before surgery. However it was felt by the pathway development group that it may be difficult for some patients in this category to achieve. So need for a patient to attempt weight loss is not required before surgery as long as the GP has assessed that weight loss is an unrealistic option.

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29. Refer to MSK-TAS (Telephone Assessment Service) Form (MSK5)

Quick info:
Referral Form:
MSK5 Knee Replacement Triage Form V3

Choose & Book
You can find this clinic on Choose & Book under:
Speciality: Orthopaedics
Clinic Type: Knee

The MSK Telephone Assessment Service (MSK-TAS) is offered as a way of esuring patients get into the right clinic when it is not clear from the pathways what the right coarse of action is.

This is distinct from the Diagnosis Unclear Pathway which is there to offer quick access to diagnostic assessment when patients present with symptoms that don't immediately fall into a diagnostic group.

Patients who are appropriate for the MSK-TAS fall into two categories:

Those who have a clear problem but there is no Leeds pathway and so you are ensure of where to refer the patient.

Those with a clear problem and coarse of action but you are unable to make the referral because of referral restrictions caused by some pathways still not allowing GPs to directly refer to the appropriate surgeon. Pathways where these restrictions still occur are the Shoulder / Elbow, Spine, Knee and Foot / Ankle.

When you book the patient into the MSK-TAS via Choose & Book you are booking them a telephone appointment.

Once the referral form has been completed and sent via Choose & Book a senior Physiotherapist will review the referral form within

48 hours. They will then decided the appropriate coarse of action and the patient will be contacted by phone at the allotted time in order to make the necessary arrangements for onward referral.

Key Dates

Published: 09-0ct-2015, by Leeds
Valid until: 17-Jun-2016

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