1 Tower Hamlets Clinical Commissioning Group Osteoarthritis of Knee and Hip Care Pathway Osteoarthritis Knee and Hip Key features Very common, the older the patient, the greater their risk of OA. Family history common. Symptoms include: joint pain - generally worse with prolonged weight-bearing, stiffness - usually less than 30 minutes of early morning stiffness, but stiffness after inactivity is common, decreased joint mobility, joint swelling, crepitus, and recurring pain throughout the day or during movement at night. Differential Diagnosis Consider inflammatory arthritis and refer to rheumatology if: Morning stiffness lasts longer than 30 minutes, pain is worse at night, stiffness and pain are relieved by activity, bilateral symptoms, metacarpophalangeal (MCP), metatarsophalangeal (MTP), wrist, elbow, or ankle joints are involved. Also consider: fibromyalgia, septic arthritis, fracture of the bone adjacent to the joint, major ligamentous injury (recent and old injuries). in adults, most complaints of the knee 'giving way' reflect poor muscle strength, bursitis. Cancer (rare, but consider if pain is persistent with no relief at night). Management in primary care Investigations: X-rays: if needed to exclude other diagnosis. In OA findings are often non- specific, and may be absent in the early stages Information and advice (see below for resources): counter misconceptions that OA inevitably progresses and cannot be treated Exercise: The benefits of exercise on pain and function are comparable to those reported for NSAIDs. Pain may get worse with exercises due to increased work, but it does not mean harm is being done. If pain is severe, rest for a few days and build up more slowly. Weight loss: has been shown to reduce pain and physical disability in obese people with knee OA Assistive devices: Consider advice from: occupational therapists, physiotherapists, podiatrists. Patients with biomechanical joint pain or instability should be assessed for: bracing, joint support, insoles or shock absorbing footwear advice. Physiotherapy: for stretching and strengthening exercises, education, pacing advice, muscle balancing, taping. Medication: Paracetamol, topical NSAIDs (for knee OA), capsaicin (for knee OA), oral NSAID/COX-2 inhibitors (according to the formulary and BNF). Opioids should only be used for patients in whom other analgesia is contraindicated or ineffective. Intra-articular corticosteroid injections reduce inflammation in the knee joint, should be considered as an adjunct to core treatment in patients with moderate to severe knee pain. Effect is usually short-lived. Guidelines disagree on the value of acupuncture or glucosamine and these are not recommended. Osteoarthritis of Knee and Hip Care Pathway November 2011 Tower Hamlets Only
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OsteoarthritisTower Hamlets Clinical Commissioning Group
Osteoarthritis of Knee and Hip Care Pathway Osteoarthritis Knee and Hip Key features Very common, the older the patient, the greater their risk of OA. Family history common.
Symptoms include: joint pain - generally worse with prolonged weight-bearing, stiffness - usually less than 30 minutes of early morning stiffness, but stiffness after inactivity is common, decreased joint mobility, joint swelling, crepitus, and recurring pain throughout the day or during movement at night.
Differential Diagnosis
Consider inflammatory arthritis and refer to rheumatology if: Morning stiffness lasts longer than 30 minutes, pain is worse at night, stiffness and pain are relieved by activity, bilateral symptoms, metacarpophalangeal (MCP), metatarsophalangeal (MTP), wrist, elbow, or ankle joints are involved. Also consider: fibromyalgia, septic arthritis, fracture of the bone adjacent to the joint, major ligamentous injury (recent and old injuries). in adults, most complaints of the knee 'giving way' reflect poor muscle strength, bursitis. Cancer (rare, but consider if pain is persistent with no relief at night).
Management in primary care
Investigations: X-rays: if needed to exclude other diagnosis. In OA findings are often non- specific, and may be absent in the early stages Information and advice (see below for resources): counter misconceptions that OA inevitably progresses and cannot be treated Exercise: The benefits of exercise on pain and function are comparable to those reported for NSAIDs. Pain may get worse with exercises due to increased work, but it does not mean harm is being done. If pain is severe, rest for a few days and build up more slowly. Weight loss: has been shown to reduce pain and physical disability in obese people with knee OA Assistive devices: Consider advice from: occupational therapists, physiotherapists, podiatrists. Patients with biomechanical joint pain or instability should be assessed for: bracing, joint support, insoles or shock absorbing footwear advice. Physiotherapy: for stretching and strengthening exercises, education, pacing advice, muscle balancing, taping. Medication: Paracetamol, topical NSAIDs (for knee OA), capsaicin (for knee OA), oral NSAID/COX-2 inhibitors (according to the formulary and BNF). Opioids should only be used for patients in whom other analgesia is contraindicated or ineffective. Intra-articular corticosteroid injections reduce inflammation in the knee joint, should be considered as an adjunct to core treatment in patients with moderate to severe knee pain. Effect is usually short-lived. Guidelines disagree on the value of acupuncture or glucosamine and these are not recommended.
Osteoarthritis of Knee and Hip Care Pathway
November 2011 Tower Hamlets Only
2
Refer to MSK CAS • If unable to offer steroid injections at the practice or If in doubt with the diagnosis
When to refer for surgery
• Where symptoms have a substantial impact on the patient's quality of life • When symptoms are refractory to non-surgical treatment and • The patient is keen on surgery Patient-specific factors should not be a barrier to referral for joint surgery, including: age, gender, smoking status, obesity, co-morbidities. But there are added risks when co- morbidities are present and patients should be encouraged to lose weight prior to surgery. Do not use scoring tools (e.g. New Zealand score, Oxford hip or knee score) as the sole basis for referral.
Knee Hip Surgical management and follow up
Knee replacement 1) Total knee replacement has a
high success rate. Patients are usually followed up: in the first postoperative year, at 5 years, 5 year intervals thereafter.
2) Arthroscopic lavage and debridement: should only be offered to patients with knee arthritis who have a clear history of mechanical locking.
3) Arthroscopic partial meniscectomy or loose body removal in patients with primary signs and symptoms of a torn meniscus or loose body.
Hip replacement Follow-up after hip replacement: 1) All patients should have a follow-up consultant
appointment at 6 weeks. 2) Ensure patients are followed up clinically and
radiologically in the longer term to monitor implants - some implants fail before 10 years.
3) Take a history of any complaints, clinical examination, and arrange antero-posterior (AP) and lateral X-rays at: 1 year, 5 years and every 5 years after operation.
4) Be aware of failure from aseptic loosening of the prosthesis - this is often silent and so the patient may not complain.
Referral for arthroscopic lavage and debridement should not be offered to patients with arthritis of the hip.
Information for patients
[email protected] [email protected]
Acknowledgements
This pathway work was partly funded by Arthritis Research UK Authors: Dr Victoria Tzortziou Brown ([email protected]) Dr Kambiz Boomla ([email protected]) Dr Sally Hull ([email protected])
Clinical Effectiveness Group | Centre for Primary Care and Public Health | Blizard Institute
Barts and The London School of Medicine and Dentistry | Yvonne Carter Building 58 Turner Street | London E1 2AB | Phone: 020 7882 2553 | Fax: 020 7882 2552
email: [email protected] | www.icms.qmul.ac.uk/chs/ceg/
Osteoarthritis of Knee and Hip Care Pathway Osteoarthritis Knee and Hip Key features Very common, the older the patient, the greater their risk of OA. Family history common.
Symptoms include: joint pain - generally worse with prolonged weight-bearing, stiffness - usually less than 30 minutes of early morning stiffness, but stiffness after inactivity is common, decreased joint mobility, joint swelling, crepitus, and recurring pain throughout the day or during movement at night.
Differential Diagnosis
Consider inflammatory arthritis and refer to rheumatology if: Morning stiffness lasts longer than 30 minutes, pain is worse at night, stiffness and pain are relieved by activity, bilateral symptoms, metacarpophalangeal (MCP), metatarsophalangeal (MTP), wrist, elbow, or ankle joints are involved. Also consider: fibromyalgia, septic arthritis, fracture of the bone adjacent to the joint, major ligamentous injury (recent and old injuries). in adults, most complaints of the knee 'giving way' reflect poor muscle strength, bursitis. Cancer (rare, but consider if pain is persistent with no relief at night).
Management in primary care
Investigations: X-rays: if needed to exclude other diagnosis. In OA findings are often non- specific, and may be absent in the early stages Information and advice (see below for resources): counter misconceptions that OA inevitably progresses and cannot be treated Exercise: The benefits of exercise on pain and function are comparable to those reported for NSAIDs. Pain may get worse with exercises due to increased work, but it does not mean harm is being done. If pain is severe, rest for a few days and build up more slowly. Weight loss: has been shown to reduce pain and physical disability in obese people with knee OA Assistive devices: Consider advice from: occupational therapists, physiotherapists, podiatrists. Patients with biomechanical joint pain or instability should be assessed for: bracing, joint support, insoles or shock absorbing footwear advice. Physiotherapy: for stretching and strengthening exercises, education, pacing advice, muscle balancing, taping. Medication: Paracetamol, topical NSAIDs (for knee OA), capsaicin (for knee OA), oral NSAID/COX-2 inhibitors (according to the formulary and BNF). Opioids should only be used for patients in whom other analgesia is contraindicated or ineffective. Intra-articular corticosteroid injections reduce inflammation in the knee joint, should be considered as an adjunct to core treatment in patients with moderate to severe knee pain. Effect is usually short-lived. Guidelines disagree on the value of acupuncture or glucosamine and these are not recommended.
Osteoarthritis of Knee and Hip Care Pathway
November 2011 Tower Hamlets Only
2
Refer to MSK CAS • If unable to offer steroid injections at the practice or If in doubt with the diagnosis
When to refer for surgery
• Where symptoms have a substantial impact on the patient's quality of life • When symptoms are refractory to non-surgical treatment and • The patient is keen on surgery Patient-specific factors should not be a barrier to referral for joint surgery, including: age, gender, smoking status, obesity, co-morbidities. But there are added risks when co- morbidities are present and patients should be encouraged to lose weight prior to surgery. Do not use scoring tools (e.g. New Zealand score, Oxford hip or knee score) as the sole basis for referral.
Knee Hip Surgical management and follow up
Knee replacement 1) Total knee replacement has a
high success rate. Patients are usually followed up: in the first postoperative year, at 5 years, 5 year intervals thereafter.
2) Arthroscopic lavage and debridement: should only be offered to patients with knee arthritis who have a clear history of mechanical locking.
3) Arthroscopic partial meniscectomy or loose body removal in patients with primary signs and symptoms of a torn meniscus or loose body.
Hip replacement Follow-up after hip replacement: 1) All patients should have a follow-up consultant
appointment at 6 weeks. 2) Ensure patients are followed up clinically and
radiologically in the longer term to monitor implants - some implants fail before 10 years.
3) Take a history of any complaints, clinical examination, and arrange antero-posterior (AP) and lateral X-rays at: 1 year, 5 years and every 5 years after operation.
4) Be aware of failure from aseptic loosening of the prosthesis - this is often silent and so the patient may not complain.
Referral for arthroscopic lavage and debridement should not be offered to patients with arthritis of the hip.
Information for patients
[email protected] [email protected]
Acknowledgements
This pathway work was partly funded by Arthritis Research UK Authors: Dr Victoria Tzortziou Brown ([email protected]) Dr Kambiz Boomla ([email protected]) Dr Sally Hull ([email protected])
Clinical Effectiveness Group | Centre for Primary Care and Public Health | Blizard Institute
Barts and The London School of Medicine and Dentistry | Yvonne Carter Building 58 Turner Street | London E1 2AB | Phone: 020 7882 2553 | Fax: 020 7882 2552
email: [email protected] | www.icms.qmul.ac.uk/chs/ceg/
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