Welcome to NGC. Skip directly to: Search Box, Navigation, Content.

Brief Summary

GUIDELINE TITLE

Review criteria for knee surgery.

BIBLIOGRAPHIC SOURCE(S)

  • Washington State Department of Labor and Industries. Review criteria for knee surgery. Provider Bull 2003 Dec;(PB 03-16):1-7. [8 references]

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Washington State Department of Labor and Industries. Criteria for knee surgery. Olympia (WA): Washington State Department of Labor and Industries; 1999 Jun (republished Aug 2002).

BRIEF SUMMARY CONTENT

 RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Review Criteria for Knee Surgery

PROCEDURE CONSERVATIVE CARE Clinical Findings
      SUBJECTIVE   OBJECTIVE   IMAGING

ANTERIOR CRUCIATE LIGAMENT (ACL) REPAIR

(Not required for acute injury with hemarthrosis)

Physical therapy

OR

Brace

AND

Pain alone is not an indication for surgery

Instability of the knee, described as "buckling or give way"

OR

Significant effusion at the time of injury

OR

Description of injury indicates rotary twisting or hyperextension incident

AND

Positive Lachman's sign

OR

Positive pivot shift

OR

Positive anterior drawer

OR

Positive KT 1000
>3-5 mm = +1
>5-7 mm = + 2
>7 mm = +3

AND

(Not required if acute effusion, hemarthrosis, and instability; or documented history of effusion, hemarthrosis, and instability)

ACL disruption on:

Magnetic resonance imaging (MRI)

OR

Arthroscopy

OR

Arthrogram

LATERAL RETINACULAR RELEASE
OR PATELLA TENDON REALIGNMENT
OR
MAQUET PROCEDURE

Physical therapy (not required for acute patellar dislocation with associated intra-articular fracture)

OR

Medications

AND

Knee pain with sitting

OR

Pain with patellar/femoral movement

OR

Recurrent dislocations

AND

Lateral tracking of the patella

OR

Recurrent effusion

OR

Patellar apprehension

OR

Synovitis with or without crepitus

OR

Increased Q angle >15 degrees

AND

Abnormal patellar tilt on:

x-ray, computed tomography (CT), or MRI

KNEE JOINT REPLACEMENT

If only 1 compartment is affected, a unicompartmental or partial replacement is indicated.

If 2 of the 3 compartments are affected, a total joint replacement is indicated.

Medications

OR

Visco supplementation injections

OR

Steroid injection

AND

Limited range of motion

OR

Night time joint pain

OR

No pain relief with conservative care

AND

Over 50 years of age

AND

**Body Mass Index of less than 35

AND

Osteoarthritis on:

Standing x-ray

OR

Arthroscopy

DIAGNOSTIC ARTHROSCOPY

Medications

OR

Physical therapy

AND

Pain and functional limitations continue despite conservative care

 

AND

Imaging is inconclusive

MENISCECTOMY
OR
MENISCUS REPAIR

(Not required for locked/blocked knee)

Physical therapy

OR

Medication

OR

Activity modification

AND

Joint pain

OR

Swelling

OR

Feeling of give way

OR

Locking, clicking, or popping

AND

Positive McMurray's sign

OR

Joint line tenderness

OR

Effusion

OR

Limited range of motion

OR

Locking, clicking, or popping

OR

Crepitus

AND

(Not required for locked/blocked knee)

Meniscal tear on MRI

CHONDROPLASTY
(Shaving or debridement of an articular surface)

Medication

OR

Physical therapy

AND

Joint pain

AND

Swelling

AND

Effusion

OR

Crepitus

OR

Limited range of motion

 

SUBCHONDRAL DRILLING OR MICROFRACTURE

Medication

OR

Physical therapy

AND

Joint pain

AND

Swelling

AND

Small full thickness chondral defect on the weight bearing portion of the medial or lateral femoral condyle

AND

Knee is stable with intact, fully functional menisci and ligaments

AND

Normal knee alignment

AND

Normal joint space

AND

Ideal age 45 or younger

AND

Chondral defect on the weight-bearing portion of the medial or lateral femoral condyle on:

MRI

OR

Arthroscopy

OSTEOCHONDRAL AUTOGRAFT (MOSAICPLASTY OR OSTEOCHONDRAL AUTOGRAPH TRANSFER SYSTEM [OATS] PROCEDURE)

Medication

OR

Physical therapy

AND

Joint pain

AND

Swelling

AND

Failure of previous subchondral drilling or microfracture

Large full thickness chondral defect that measures less than 3 cm in diameter and 1 cm in bone depth on the weight bearing portion of the medial or lateral femoral condyle

AND

Knee is stable with intact, fully functional menisci and ligaments

AND

Normal knee alignment

AND

Normal joint space

AND

**Body mass index of less than 35

AND

Chondral defect on the weight-bearing portion of the medial or lateral femoral condyle on:

MRI

OR

Arthroscopy

AUTOLOGOUS CHONDROCYTE IMPLANTATION (ACI)

Physical therapy for a minimum of 2 months

AND

Injured worker (IW) is capable and willing to follow the rehabilitation protocol.

AND

Failure of traditional surgical interventions (i.e., microfracture, drilling, abrasion, osteochondral graft). Debridement alone does not constitute a traditional surgical intervention for ACI

AND

Single, clinically significant, lesion that measures between 1 to 10 sq cm in area that affects a weight-bearing surface of the medial femoral condyle or the lateral femoral condyle.

AND

Full-thickness lesion (*Modified Outerbridge Grade III-IV) that involves only cartilage

AND

Knee is stable with intact, fully functional menisci and ligaments.

AND

Normal knee alignment

AND

Normal joint space

AND

IW is less than 60 years old.

AND

**Body Mass Index of less than 35

AND

Chondral defect on the weight-bearing surface of the medial or lateral femoral condyle on:

MRI

OR

Arthroscopy

ACI Exclusion Criteria

ACI is not a covered procedure in any of the following circumstances:

  • Lesion that involves any portion of the patellofemoral articular cartilage, bone, or is due to osteochondritis dissecans
  • A "kissing lesion" or *Modified Outerbridge Grade II, III, or IV exists on the opposite tibial surface.
  • Mild to severe localized or diffuse arthritic condition that appears on standing x-ray as joint space narrowing, osteophytes, or changes in the underlying bone
  • Unhealthy cartilage border; the synovial membrane in the joint may be used as a substitute border for up to 1/4 of the total circumference.
  • Prior total meniscectomy of either compartment in the affected knee. Must have at least 1/3 of the posterior meniscal rim.
  • History of anaphylaxis to gentamycin or sensitivity to materials of bovine origin
  • Chondrocalcinosis is diagnosed during the cell culture process.

Please refer to Provider Bulletin 03-02 for additional coverage information. Surgeon should have performed or assisted in 5 or more ACI procedures; or will be performing the ACI under the direct supervision and control of a surgeon who has experience with 5 ACI procedures.

Inclusion Criteria

PROCEDURE CONSERVATIVE CARE Clinical Findings
      SUBJECTIVE   OBJECTIVE   IMAGING

MENISCAL ALLOGRAFT TRANSPLANTATION

Physical therapy

OR

Nonsteroidal anti-inflammatory drugs (NSAID)

OR

Activity modification

AND

Capable and willing to follow the rehabilitation protocol

AND

Knee pain that has not responded to conservative treatment

AND

Previous meniscectomy with at least two-thirds of the meniscus removed

AND

If *Modified Outerbridge Scale Grade III then debridement must first produce an articular surface sufficiently free of irregularities to maintain the integrity of the transplanted meniscus.

AND

Stable knee with intact ligaments, normal alignment, and normal joint space

AND

Ideal age 20-45 years (too young for total knee)

AND

**Body Mass Index of less than 35

AND

Articular cartilage in the affected compartment demonstrates a chondrosis classified by the *Modified Outerbridge Scale as Grade I, Grade II, or Grade III.

Meniscal Allograft Transplantation Exclusion Criteria

Meniscal Allograft Transplantation is not a covered procedure in any of the following circumstances:

  • Mild to severe localized or diffuse arthritic condition that appears on standing x-ray as joint space narrowing, osteophytes, or changes in the underlying bone
  • Articular cartilage in the affected compartment demonstrates a chondrosis classified by the *Modified Outerbridge Scale as Grade III that has not undergone debridement; Grade III with debridement that has not produced an articular surface that can maintain the integrity of the transplanted meniscus; or Grade IV.

Please refer to Provider Bulletin 03-02 for additional coverage information. Surgeon should have performed or assisted in 5 or more meniscal allograft transplantation procedures; or will be performing the meniscal allograft transplantation under the direct supervision and control of a surgeon who has experience with 5 procedures.

(Refer to the original Guideline for a listing of the knee surgeries that will and will not require utilization review).

*Modified Outerbridge Classification

  1. Articular cartilage softening
  2. Chondral fissures or fibrillation <1.25 cm in diameter
  3. Chondral fibrillation >1.25 cm in diameter ("crabmeat changes")
  4. Exposed subchondral bone

**Body Mass Index: The equation for calculating the Body Mass Index (BMI) = (Weight in pounds ÷ Height in inches ÷ Height in inches) x 703. For example, a person weighing 210 pounds and 6 feet tall would have a BMI of (210 pounds ÷ 72 inches ÷ 72 inches) x 703 = 28.5.

CLINICAL ALGORITHM(S)

None provided

Top^

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each recommendation.

The recommendations were developed by combining pertinent evidence from the medical literature with the opinions of clinical expert consultants and community-based practicing physicians. Because of a paucity of specific evidence related to the injured worker population, the guideline is more heavily based on expert opinion.

Top^

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • Washington State Department of Labor and Industries. Review criteria for knee surgery. Provider Bull 2003 Dec;(PB 03-16):1-7. [8 references]

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

1991 Jan (revised 2004 Jan)

GUIDELINE DEVELOPER(S)

Washington State Department of Labor and Industries - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

Washington State Department of Labor and Industries

GUIDELINE COMMITTEE

Washington State Department of Labor and Industries (L&I), Washington State Medical Association (WSMA) Industrial Insurance Advisory Section of the Interspecialty Council

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Medical Director, Washington State Department of Labor and Industries (L&I): Gary Franklin, MD

The individual names of the Washington State Medical Association (WSMA) Industrial Insurance Advisory Committee are not provided in the original guideline document.

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: Washington State Department of Labor and Industries. Criteria for knee surgery. Olympia (WA): Washington State Department of Labor and Industries; 1999 Jun (republished Aug 2002).

GUIDELINE AVAILABILITY

Electronic copies: Available from the Washington State Department of Labor and Industries Web site.

Print copies: L&I Warehouse, Department of Labor and Industries, P.O. Box 44843, Olympia, Washington 98504-4843.

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

Print copies are available from the L&I Warehouse, Department of Labor and Industries, P.O. Box 44843, Olympia, Washington 98504-4843.

PATIENT RESOURCES

None available

NGC STATUS

This summary was completed by ECRI on February 14, 2000. It was sent to the guideline developer for review on February 15, 2000; however, to date, no comments have been received. The guideline developer has given NGC permission to publish the NGC summary. This summary was updated by ECRI on May 28, 2004. The information was verified by the guideline developer on June 14, 2004.

COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

Top^

DISCLAIMER

NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce, approve, or endorse the guidelines represented on this site.

All guidelines summarized by NGC and hosted on our site are produced under the auspices of medical specialty societies, relevant professional associations, public or private organizations, other government agencies, health care organizations or plans, and similar entities.

Guidelines represented on the NGC Web site are submitted by guideline developers, and are screened solely to determine that they meet the NGC Inclusion Criteria which may be found at http://www.guideline.gov/about/inclusion.aspx .

NGC, AHRQ, and its contractor ECRI Institute make no warranties concerning the content or clinical efficacy or effectiveness of the clinical practice guidelines and related materials represented on this site. Moreover, the views and opinions of developers or authors of guidelines represented on this site do not necessarily state or reflect those of NGC, AHRQ, or its contractor ECRI Institute, and inclusion or hosting of guidelines in NGC may not be used for advertising or commercial endorsement purposes.

Readers with questions regarding guideline content are directed to contact the guideline developer.
Top^

 


Search Help
Detailed Search
Frequent Searches

Summary

Brief Summary
Complete Summary
XML View
Full Text
Palm Download
MS Word
Adobe PDF

Browse

» Disease / Condition
» Treatment / Intervention
» Measures
» Organization
» Guideline Index
» Guidelines In Progress
» Guideline Archive

Compare

» View My Collection
» Add to My Collection
» Guideline Syntheses

 

   
DHHS Logo