Policies for the Commissioning of Healthcare

 

Policy for Elective Endoscopic Procedures on the Knee Joint Cavity

 

 

1

Introduction

 

 

1.1

This document is part of a suite of policies that the CCG uses to drive its commissioning of healthcare. Each policy in that suite is a separate public document in its own right but will be applied with reference to other polices in that suite.

 

 

1.2

This policy is based on the CCGs Statement of Principles for Commissioning of Healthcare (version in force on the date on which this policy is adopted).

 

 

2

Scope and definitions

 

 

2.1

Knee Arthroscopy is a surgical technique whereby a small telescope is inserted into a joint to inspect, diagnose and treat intra-articular problems. Knee irrigation or washout involves flushing the joint with fluid, which is introduced through small incisions in the knee.

 

 

2.2

The scope of this policy includes requests for an endoscopic procedure on the knee joint cavity for patients 16 and over. Procedures include:

·       Removal/repair of torn meniscus

·       Lateral release

·       Arthroscopic washout

·       Diagnostic arthroscopy

·       Plica reconstruction

·       Autologous chondrocyte implantation

·       Micro fracture

 

 

2.3

Endoscopic procedures on the knee joint cavity have the intended outcome of diagnosing or treating conditions affecting the knee joint. These conditions include:

·       Damaged ligaments or cartilage

·       Loose bodies within the knee joint

·       Patellofemoral syndrome

·       Plica syndrome

 

 

2.4

The CCG recognises that a patient may:

·       Suffer from one of the conditions listed in 2.3

·       Wish to have a service provided for their condition

·       Be advised that they are clinically suitable for an endoscopic procedure on the knee joint cavity, and

·       Be distressed by their condition and by the fact that that they may not meet the criteria specified in this commissioning policy.

Such features place the patient within the group to whom this policy applies and do not make them exceptions to it.

 

 

3

Appropriate Healthcare

 

 

3.1

The Commissioning Organisation considers that the purpose of these procedures is to improve the health of patients by reducing pain, discomfort and disability and, therefore, accords with the Principle of Appropriateness in the Statement of Principles.

 

 

4

Effective Healthcare

 

 

4.1

The Commissioning Organisation recognises that endoscopic procedures on the knee joint cavity are effective in the following circumstances:

 

·    Arthroscopic repair of mechanical damage to the cartilage and ligaments of the knee joint cavity for patients who have MRI confirmation of injury and where the specialist opinion that the benefits of the procedure outweigh the risk of harm.

 

 

 

 

4.2

The Commissioning Organisation considers that endoscopic procedures on the knee joint cavity are not effective in the following circumstances:

 

  • Arthroscopic washout or debridement of an osteoarthritic knee in the absence of mechanical locking

 

  • To determine the diagnosis of knee symptoms in the absence of a prior MRI scan, except where an MRI scan is contraindicated.

 

  • Endoscopic plica resection for the second line treatment of patients with plica syndrome in whom conservative management has failed.

 

  • Autologous chondrocyte implantation for the treatment of knee problems caused by damaged articular cartilage except in the context of ongoing or new clinical studies that are designed to generate robust and relevant outcome data, including the measurement of health related quality of life and long-term follow-up (Ref 3).

 

·       Micro fracture for the management of articular cartilage lesions.

 

 

5

Cost Effectiveness

 

 

5.1

The Commissioning Organisation considers that endoscopic procedures on the knee joint cavity are cost effective in 4.1 above.

 

 

5.2

The commissioning organisation considers that endoscopic procedures on the knee joint cavity are not cost effective in 4.2 above

Nevertheless if a patient is considered exceptional in relation to the principles on which the policy does rely, the CCG may consider whether the treatment is likely to be Cost Effective in this patient before confirming a decision to provide funding.

 

 

6

Ethics

 

 

6.1

The Commissioning Organisation recognises that endoscopic procedures on the knee joint cavity satisfy the criteria within the ‘Ethical’ component of the Statement of Principles.

 

 

7

Affordability

 

 

7.1

The Commissioning Organisation recognises that this policy satisfies the criteria within the ‘Affordability’ component of the Statement of Principles

 

 

8

Policy

 

 

8.1

 

The commissioning organisation commissions endoscopic procedures on the knee joint cavity in the following circumstances:

 

 

8.1.1

 

Where the patient has had an acute injury and an MRI scan reveals a potentially repairable meniscal tear

 

OR

8.1.2

 

There is evidence of mechanical damage to the ligaments which need repair/reconstruction.

 

OR

8.1.3

 

Where the patient has a locked knee (mechanical block to extension) if a bucket handle tear of the meniscus is present

 

OR

8.1.4

 

There is a palpable loose body or a loose body seen on x-ray which is considered to be causing symptoms of pain and disability.

 

OR

8.1.5

There is evidence of haemarthrosis or osteochondral injury on x-ray.

 

OR

8.1.6

Where the MRI scan is inconclusive or contraindicated, it will be for the specialist to make a clinical judgement on whether an arthroscopy is required, based on the patients’ history and findings.

 

AND

8.1.7

The documented specialist clinical opinion is that the benefit of the procedure outweighs the risk of harm. This includes those patients for whom an MRI scan is contraindicated

 

 

8.2

 

The commissioning organisation does not commission endoscopic procedures on the knee joint cavity in the following circumstances:

 

 

8.2.1

Where the procedure is to undertake a washout or debridement of an osteoarthritic knee in the absence of mechanical locking

 

 

8.2.2

 

Where the procedure is undertaken to treat chondral defects by re-establishing the articular surface of the knee joint e.g. autologous cartilage implantation, marrow stimulation techniques including abrasion arthroplasty, drilling and micro fracture and mosaicplasty/osteochondral transplantation

 

 

8.2.3

Endoscopic plica resection for the second line treatment of patients with plica syndrome in whom conservative management has failed.

 

 

8.2.4

To determine the diagnosis of knee symptoms in the absence of a prior MRI scan, except where an MRI scan is contraindicated.

 

 

9

Exceptions

 

 

9.1

The CCG will consider exceptions to this policy in accordance with the Policy for Considering Applications for Exceptionality to Commissioning Policies.

 

 

10

Force

 

 

10.1

This policy remains in force for a period of three years from the date of its adoption, or until it is superseded by a revised policy, whichever is sooner.

 

 

10.2

In the event of NICE guidance referenced in this policy being superseded by new NICE guidance, then:

·     If the new NICE guidance has mandatory status, then that NICE guidance will supersede this policy with effect from the date on which it becomes mandatory.

·     If the new NICE guidance does not have mandatory status, then the CCG will aspire to review and update this policy accordingly.  However, until the CCG adopts a revised policy, this policy will remain in force and any references in it to NICE guidance will remain valid as far as the decisions of this CCG are concerned.

 

 

11

References

 

1.    NICE CG177 Osteoarthritis:  care and management (2014).  Last updated 11 December 2020, section 1.4.10

 

     2.   NICE IPG 230 Arthroscopic knee washout, with or without debridement (2007)

 

     3.   Evidence-Based Interventions.  List 2 Guidance.  Academy of Royal Colleges.  November 2020.

 

     4.   Commissioning Guide: Painful osteoarthritis of the Knee. British Association of Knee Surgery (BASK) and British Orthopaedic Association (BOA). (2013)

 

Date of adoption:       02 November 2017

Date for review:         02 November 2020

 

 

 

Appendix 1

 

 

1.1

Codes

The codes applicable to this policy are: to be checked when draft approved

 

OPCS codes

ICD codes

W821, W822, W823, W828, W829, W831, W848, W851, W858, W859, W861, W868, W869, W843, W852, W853, W879

M222, M234, M236, M239, M250, M939 M2351, M2352-M2354, M2357, M2359-M2364, M2367, M2369, M2381-M2384, M2387, M2389, M2391-M2394, M2397, M2399, S834,  Q778-779, Q788-789,

 

 

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