TNRF2: Musculoskeletal (MSK)

Overview

Balloon Kyphoplasty (KP) is a procedure used for the treatment of osteoporotic vertebral compression fractures. The primary aim is to restore mobility, reduce pain and minimise the incidence of new fractures.

Thresholds and eligibility 

NICE Interventional Procedure Guidance 166 supports the use of balloon kyphoplasty if the procedure is undertaken following discussion with a specialist multidisciplinary team that includes a radiologist and a spinal surgeon.

The guidance also states that there should be good imaging facilities, arrangements for access to a spinal surgery service and that clinicians reach an appropriate level of expertise before carrying out the procedures. In particular, they must follow the manufacturer's instructions for making the cement, to reduce the risk of embolisation. 

NHS Surrey Heartlands expect this service to be provided at centres that fulfil all the conditions stipulated by NICE. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

 A discectomy is carried out to release the pressure on your spinal nerves caused by a bulging or slipped disc.

Thresholds and eligibility 

This procedure is not routinely funded unless: 

• The patient has had appropriate imaging e.g., MRI or CT showing disherniation (protrusion, extrusion, or sequestered fragment) at a level and side corresponding to the clinical symptoms.

AND

• The patient has radicular pain (below the knee for lower lumbar herniations; into the anterior thigh for upper lumbar herniations) consistent with the level of spinal involvement.

 
OR

•  There is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise-positive between 30o and 70o or positive femoral tension sign).

AND 

• Symptoms persist despite some non-operative treatment for at least 6 weeks (e.g., analgesia, physiotherapy, bed rest, etc.), provided that analgesia is adequate and there is no imminent risk of neurological deficit.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Spinal fusion is surgery to connect two or more bones in any part of the spine. Connecting them prevents movement between them. Preventing movement helps to prevent pain.

During spinal fusion, a surgeon places bone or a bonelike material in the space between two spinal bones.

Thresholds and eligibility 

This procedure will only be funded in line with NICE guideline NG59 and the National Low Back Pain Pathway (2017).

Spinal fusion is not offered to people with non-specific low back pain unless as part of a randomised controlled trial.

Spinal fusion may be considered for patients who: 

• Have not responded to conservative* management. 

AND

• Have significant back pain accompanying radicular pain with localised degenerative changes.

OR

• Have other specific pathologies and conditions as listed below: 
  • Spondylolysis and significant spondylolisthesis (Grade 2 or greater). 
  • Lumbar deformity in children and adults. 
  • Decompression for spinal stenosis with symptoms of claudication.
  • Post-surgical back pain where multiple revision surgery is required.
• Conservative management includes but is not limited to the following:
  • Self-management and continue with normal activities as much as possible.
  • Exercise and relaxation techniques.
  • Manual therapies (spinal manipulation, mobilisation, soft tissue techniques such as massage) as part of a treatment package.
  • Analgesics.
  • NSAIDS (if not tolerated, ineffective or contraindicated consider weak opioids).
  • Psychological therapies (as part of a treatment package).
  • Return to work programme.
  • Low Intensity Comprehensive Combined Physical and Psychological Programmes (CPPPs) if available. 

Consider specialist triage review 12-18 weeks following initial presentation and conservative management.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Percutaneous vertebroplasty is a procedure that allows a medical practitioner, usually a radiology consultant or surgeon from a spinal team, to inject liquid bone cement, via a needle inserted through the skin and using image guidance, into the fractured vertebrae.

The cement acts as a glue that holds the vertebrae together. This helps to remove pain in the back and prevent further damage in the spine. 

Thresholds and eligibility 

This procedure will only be funded in line with NICE IPG 12.

This procedure should only be undertaken when there are arrangements for good access to a spinal surgery service, and with prior discussion between a specialist multidisciplinary team that includes a radiologist and a spinal surgeon. Clinicians should receive training to reach an appropriate level of expertise before carrying out this procedure. In particular, they must follow the manufacturer’s instructions for making the cement, to reduce the risk of embolisation. 

The procedure should be limited to patients whose pain is refractory to more conservative treatment. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Hallux Valgus, commonly referred to as a bunion, is a complex valgus deformity of the first ray that can cause medial big toe pain and difficulty with shoe wear.

The aim of the surgery is to reduce pain and restore normal function by correcting the deformity.

It is achieved by cutting the involved bones and shifting them into the correct position, together with rebalancing the soft tissues around the big toe joint.

Thresholds and eligibility 

Surgery is offered if symptoms are severe or deteriorating and the risk-benefit ratio is judged favourable.

Conservative management measures should have been tried and should have failed to resolve the condition before surgery is considered.

• There should be severe deformity causing significant functional impairment of daily activities.

OR 

• Severe pain requiring regular painkillers and causing significant functional impairment of daily activities. 

Conservative management techniques include:

• Avoiding high heeled shoes and wearing wide fitting leather shoes which stretch.
• Exercises specifically designed to alleviate the effects of a bunion and keep it flexible.
• Applying ice and elevating painful and swollen bunions.
• Use of bunion pads, splints, insoles, or shields.

Significant functional impairment is considered as: 

• Symptoms which prevent the patient fulfilling vital work or educational responsibilities.

OR

• Symptoms which prevent the patient carrying out vital domestic or carer activities.

Before consulting a specialist for surgery, patients must accept that they will be unable to drive for 6 weeks (or 2 weeks after surgery on the left foot if driving an automatic car) and will be off work for 2 weeks for a sedentary job. 

In addition to the above criteria, smoking cessation and weight management should be considered as an integral part of appropriate clinical management prior to consideration of any elective surgery (with referral to appropriate services if indicated). 

Current evidence on safety and efficacy in relation to the correction of hallux valgus using minimal access techniques is inadequate NICE (IPG 332). 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Dupuytren contracture is a painless condition that causes one or more fingers to bend toward the palm of the hand. The affected fingers can't straighten completely. Knots of tissue form under the skin. They eventually create a thick cord that can pull the fingers into a bent position. The main treatments are:

• Fasciectomy: A cut that is made along the palm and finger so the surgeon can straighten it.
• Needle fasciotomy: A needle is inserted into several places along the palm and finger to loosen and straighten it.
• Dermafasciectomy: Similar to a fasciectomy, except an additional area of skin is removed; a skin graft from elsewhere in the body can be used to replace the removed skin.

Thresholds and eligibility 

NHS Surrey Heartlands will only fund surgical treatment or interventional procedures if: 

• There is a metacarpophalangeal joint contracture of 30° or more.

OR 

• Any degree of proximal interphalangeal joint contracture.

OR 

• The patient exhibits the characteristics of Dupuytrens diathesis i.e., earlier age of onset, bilateral disease, or extra-palmar disease. 

OR 

• The patient shows recurrent symptoms of the disease. 

If an exact measurement is not possible, the clinical assessment should include an evaluation of the extent of disease and an estimate of severity/deformity. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

A ganglion cyst is a fluid-filled swelling that usually develops near a joint or tendon. The cyst can range from the size of a pea to the size of a golf ball. The  main treatment options for a ganglion cyst are:

• Draining fluid out of the cyst with a needle and syringe (aspiration).
• Cutting the cyst out using surgery.

Thresholds and eligibility 

This procedure is not routinely funded except in severe cases. 

Classification: 

• Mild - Asymptomatic lump
• Moderate
  1. Symptomatic lump; long duration of symptoms - pain lasting 3-6 months
  2. Occult ganglia – hidden ganglion
  3. Cancer-phobia – excessive fear of malignancy
• Severe
  1. Nerve or blood vessel compression with restriction of activities of daily living
  2. concern regarding diagnosis

Treatment

• All patients should be informed that most ganglia resolve spontaneously with the passage of time.
• For mild and moderate cases - reassurance and observation.
• Aspiration of cancer reassurance - refer for ultrasound / MRI if concerns re diagnosis.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Carpal tunnel syndrome is where pressure on a nerve in your wrist causes pain and numbness in your hand and fingers.

Symptoms of carpal tunnel syndrome include pain, numbness, tingling or weakness in your fingers, hand or arm. The carpal tunnel inside your wrist can be cut so it no longer puts pressure on the nerve.

Thresholds and eligibility 

This intervention will be funded if: 

• Mild cases with intermittent symptoms causing little or no interference with sleep or activities require no treatment.

Cases with intermittent symptoms which interfere with activities or sleep should first be treated with:

• Corticosteroid injection(s) (medication injected into the wrist: good evidence for short (8-12 weeks) term effectiveness).

OR

• Night splints (a support which prevents the wrist from moving during the night: not as effective as steroid injections).

Surgical treatment of carpal tunnel should be considered if one of the following criteria are met:

• The symptoms significantly interfere with daily activities and sleep symptoms and have not settled to a manageable level with either one local corticosteroid injection and/or nocturnal splinting for a minimum of 8 weeks;

OR there is either:

• a permanent (ever-present) reduction in sensation in the median nerve distribution;

OR

• muscle wasting or weakness of thenar abduction (moving the thumb away from the hand).

Nerve Conduction Studies if available are suggested for consideration before surgery to predict positive surgical outcome or where the diagnosis is uncertain.

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Trigger finger is a condition that affects one or more of the hand's tendons, making it difficult to bend the affected finger or thumb.

If a tendon or the tunnel a tendon runs through (called the tendon sheath) becomes swollen and inflamed, the tendon gets irritated and can "catch" in the tendon sheath.

Thresholds and eligibility 

One in five patients with Trigger Finger will improve without any intervention other than resting the hand and allowing the inflammation time to settle. Surrey CCGs will only fund surgical techniques for the treatment of Trigger Finger when the following criteria are met: 

• The patient has failed to respond to conservative treatment which includes two corticosteroid injections.
  • Referral for surgery should only be considered if the patient has failed to respond to both steroid injections. Given steroid injections take time to be effective, any referral or request for funding for surgery must not be made until at least 3 months has elapsed after the second corticosteroid injection.

OR

• The patient has a fixed flexion deformity that cannot be corrected. 

OR 

• The patient has diabetes. In this case the patient should be referred without first attempting conservative management. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Total hip replacement eliminates osteoarthritis in the hip entirely. Hip replacement is a surgical procedure in which the hip joint is replaced by a prosthetic implant, that is, a hip prosthesis.

Thresholds and eligibility 

NHS Surrey Heartlands will fund Total Hip Replacement for Osteoarthritis only when all other treatment options and conservative measures have been tried and failed in accordance with NICE NG226: Osteoarthritis in over 16s – Diagnosis and Management. These include an explanation that:

• Osteoarthritis is diagnosed clinically and usually does not need imaging to confirm diagnosis
• Management is guided by symptoms and physical function
• The core treatments are therapeutic exercise and weight management (if clinically appropriate), alongside information and support (see below).

Therapeutic exercise

• Therapeutic exercise tailored to individual needs
• Consider supervised therapeutic exercise sessions
• Consider combining therapeutic exercise sessions with an education programme or behavioural change approaches in a structured treatment package
• Consider manual therapy alongside therapeutic exercise

Weight Management (if clinically appropriate)

• Explain that weight loss will improve quality of life and physical function, and reduce pain
• Support them to choose a weight loss goal
• Explain that any weight loss is likely to be beneficial, but losing 10% is likely to be better than losing 5%
• See NICE’s topic page on obesity for more guidance and information

Information and support

• Tailor information to the person’s individual needs and ensure it is in an accessible format
• Advise on where people can find relevant further information

Do not offer

• Acupuncture or dry needling
• Electrotherapy treatments
• Insoles, braces, tape, splints or supports routinely

Pharmacological management

If needed, use alongside non-pharmacological treatments and to support therapeutic exercise and use the lowest effective dose for the shortest possible time.

Review with the patient whether to continue treatment and base frequency of reviews on clinical need.

Consider a topical non-steroidal anti-inflammatory drug (NSAID)

Consider an oral NSAID if topical medicines are ineffective or unsuitable and offer a gastroprotective treatment alongside

Do not offer

• Paracetamol or weak opioids routinely, unless:
  • Used infrequently for short-term pain relief
  • All other treatments are ineffective or unsuitable
• Glucosamine
• Strong opioids
• Intra-articular hyaluronan injections

Consider intra-articular corticosteroid injections for short-term relief when other pharmacological treatments are ineffective or unsuitable or to support therapeutic exercise

Referral for joint replacement

Consider referring people with hip osteoarthritis for joint replacement if

• Joint symptoms are substantially impacting on quality of life,

AND

• Non-surgical management is ineffective or unsuitable

Do not exclude people from referral for joint replacement because of age, sex or gender, smoking, comorbidities, or overweight or obesity.

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Hip Impingement Syndrome is a chronic condition caused by unwanted contact between abnormally shaped parts of the femoral neck and head (ball) of the thigh bone and the anterior rim of the acetabulum (hip socket). This results in limited hip movement, pain and ‘clicking’ of the hip joint.

Thresholds and eligibility 

Open or arthroscopic femero-acetabular surgery for hip impingement is commissioned if the following criteria are met: 

• Labral tear or impingement has been confirmed on MRI.

AND

• Where hip arthroscopy is supported in the washout of an infected native hip joint in patient’s refractory to medical management, patients with underlying disease or patients who are immunosuppressed.
• Where hip arthroscopy is supported for the removal of radiologically proven loose bodies within the hip joint with an associated acute traumatic episode. Arthroscopy is not supported as a diagnostic tool where there is suspicion of loose bodies.
• The clinician has ensured that the patient understands what is involved, is aware of the serious known complications outlined in NICE patient information and agrees to the treatment knowing that there is only evidence of symptom relief in the short and medium term.

AND

• The surgeon must have completed specialist training and have experience of providing arthroscopic hip surgery.

AND

• The provider will provide full data on 100% patients undergoing this procedure to the British Hip Society register.

AND

• The provider will undertake local review of cases to monitor safety and short-term outcomes. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Metal on Metal Hip Resurfacing is a procedure which uses a prosthesis joint made of two metal surfaces: a 'metal ball' that replaces the ball at the top of the thigh bone (femur) and a metal 'cup' that acts like the socket in the pelvis.

Thresholds and eligibility 

Metal on Metal Hip Resurfacing will be funded as per NICE TA304 guidance.

Prostheses for total hip replacement and resurfacing arthroplasty are recommended as treatment options for people with end-stage arthritis of the hip, only if the prostheses have rates (or projected rates) of revision of 5% or less at 10 years.

NHS Surrey Heartlands will fund Metal on Metal Hip Resurfacing only when all other treatment options and conservative measures have been tried and failed in accordance with NICE NG226: Osteoarthritis in over 16s – Diagnosis and Management. These include an explanation that

• Osteoarthritis is diagnosed clinically and usually does not need imaging to confirm diagnosis
• Management is guided by symptoms and physical function
• The core treatments are therapeutic exercise and weight management (if clinically appropriate), alongside information and support (see below).

Therapeutic exercise

• Therapeutic exercise tailored to individual needs
• Consider supervised therapeutic exercise sessions
• Consider combining therapeutic exercise sessions with an education programme or behavioural change approaches in a structured treatment package
• Consider manual therapy alongside therapeutic exercise

Weight Management (if clinically appropriate)

• Explain that weight loss will improve quality of life and physical function, and reduce pain
• Support them to choose a weight loss goal
• Explain that any weight loss is likely to be beneficial, but losing 10% is likely to be better than losing 5%
• See NICE’s topic page on obesity for more guidance and information

Information and support

• Tailor information to the person’s individual needs and ensure it is in an accessible format
• Advise on where people can find relevant further information

Do not offer

• Acupuncture or dry needling
• Electrotherapy treatments
• Insoles, braces, tape, splints or supports routinely

Pharmacological management

If needed, use alongside non-pharmacological treatments and to support therapeutic exercise and use the lowest effective dose for the shortest possible time.

Review with the patient whether to continue treatment and base frequency of reviews on clinical need.

Consider a topical non-steroidal anti-inflammatory drug (NSAID)

Consider an oral NSAID if topical medicines are ineffective or unsuitable and offer a gastroprotective treatment alongside

Do not offer

• Paracetamol or weak opioids routinely, unless:
  • Used infrequently for short-term pain relief
  • All other treatments are ineffective or unsuitable
• Glucosamine
• Strong opioids
• Intra-articular hyaluronan injections

Consider intra-articular corticosteroid injections for short-term relief when other pharmacological treatments are ineffective or unsuitable or to support therapeutic exercise.

Referral for metal on metal hip resurfacing

Consider referring people with hip osteoarthritis for metal on metal hip resurfacing if:

• Joint symptoms are substantially impacting on quality of life

AND

• Non-surgical management is ineffective or unsuitable

Do not exclude people from referral for metal on metal hip resurfacing because of age, sex or gender, smoking, comorbidities, or overweight or obesity.

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Knee arthroscopy is a type of keyhole surgery used to diagnose and treat knee pain or other knee problems. It can be used for inflammation, damage, injury and infections.

Thresholds and eligibility 

Arthroscopy of the knee can be undertaken where a competent clinical examination (or MRI scan if there is diagnostic uncertainty or red flag symptoms/signs/conditions) has demonstrated clear evidence of an internal joint derangement due to acute trauma/injury (meniscal tear, ligament rupture or loose body) and where conservative treatment has failed or where it is clear that conservative treatment will not be effective. 

Knee arthroscopy will not be funded in cases of degenerative knee disease with or without mechanical symptoms (with the exception of cases with true locked knee). 

Autologous chondrocyte implantation (ACI) will be funded in line with the recommendations under NICE TA477: 

• The person has not had previous surgery to repair articular cartilage defects. 

AND

• There is minimal osteoarthritis damage to the knee (as assessed by clinicians experienced in investigating knee cartilage damage using a validated measure for knee osteoarthritis.

AND

• The defect is over 2cm².

AND

• The procedure is done at a tertiary referral centre. 

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.

Overview

Total knee replacement is a surgical procedure to resurface a knee damaged by arthritis. Metal and plastic parts are used to cap the ends of the bones that form the knee joint, along with the kneecap.

Thresholds and eligibility 

NHS Surrey Heartlands will fund Total Knee Replacement for Osteoarthritis only when all other treatment options and conservative measures have been tried and failed in accordance with NICE NG226: Osteoarthritis in over 16s – Diagnosis and Management. These include an explanation that:

• Osteoarthritis is diagnosed clinically and usually does not need imaging to confirm diagnosis
• Management is guided by symptoms and physical function
• The core treatments are therapeutic exercise and weight management (if clinically appropriate), alongside information and support (see below).

Therapeutic exercise

• Therapeutic exercise tailored to individual needs
• Consider supervised therapeutic exercise sessions
• Consider combining therapeutic exercise sessions with an education programme or behavioural change approaches in a structured treatment package
• Consider manual therapy alongside therapeutic exercise

Weight Management (if clinically appropriate)

• Explain that weight loss will improve quality of life and physical function, and reduce pain
• Support them to choose a weight loss goal
• Explain that any weight loss is likely to be beneficial, but losing 10% is likely to be better than losing 5%
• See NICE’s topic page on obesity for more guidance and information

Information and support

• Tailor information to the person’s individual needs and ensure it is in an accessible format
• Advise on where people can find relevant further information

Do not offer

• Acupuncture or dry needling
• Electrotherapy treatments
• Insoles, braces, tape, splints or supports routinely

Pharmacological management

If needed, use alongside non-pharmacological treatments and to support therapeutic exercise and use the lowest effective dose for the shortest possible time.

Review with the patient whether to continue treatment and base frequency of reviews on clinical need.

Offer a topical non-steroidal anti-inflammatory drug (NSAID) for knee osteoarthritis

Consider an oral NSAID if topical medicines are ineffective or unsuitable and offer a gastroprotective treatment alongside

Do not offer

• Paracetamol or weak opioids routinely, unless:
  • Used infrequently for short-term pain relief
  • All other treatments are ineffective or unsuitable
• Glucosamine
• Strong opioids
• Intra-articular hyaluronan injections

Consider intra-articular corticosteroid injections for short-term relief when other pharmacological treatments are ineffective or unsuitable or to support therapeutic exercise.

Referral for joint replacement

Consider referring people with knee osteoarthritis for joint replacement if:

• Joint symptoms are substantially impacting on quality of life

AND

• Non-surgical management is ineffective or unsuitable

Do not exclude people from referral for joint replacement because of age, sex or gender, smoking, comorbidities, or overweight or obesity.

Patients should be encouraged to stop smoking prior to treatment, if applicable.

Resources

Treatments not routinely published policy (TNRF2)

Additional information

Assuming patients meet the criteria for this procedure, the consultant can provide the treatment.  

However, if the patients does not meet the criteria, the consultant has the option of submitting an Individual Funding Request (IFR) application to the Effective Commissioning Initiative Team at NHS Surrey Heartlands via the Blueteq database if they consider them to be clinically exceptional.