Knee

• Many musculoskeletal conditions are self-limiting and can be managed in appropriately in Primary Care by a GP or First Contact Physiotherapist (FCP) and the MSK Physiotherapy Service. Most non-urgent referrals should have been seen and assessed by the MSK Physiotherapy service, prior to onward referral, unless there is a suspicion of cancer or infection necessitating urgent referral.
• If the patient is attending MSK physiotherapy, investigations and onward referral to the knee service, if appropriate, will be organised by the MSK Physiotherapy service without further need for GP intervention.
• Where a non-acute knee condition which fails to respond to initial Primary Care management requires specialist referral for advice, assistance with management or possible surgical intervention, they should be referred to the Orthopaedic knee Service.
• Knee surgery opinion in NHS Tayside is provided by Orthopaedic surgeons, specialist knee surgeons and advanced practice physiotherapists. 

• Referrals will be vetted by any member of the multidisciplinary team, and assigned to the most appropriate member of the team. Please be aware that the first point of contact may be an advanced practice Physiotherapist.
• Where a referred patient may be more appropriately seen by another speciality, the referral may be redirected appropriately.

• Blood tests should be performed if malignancy, polymyalgia rheumatica or inflammatory arthritis are suspected.
• Those referred should have X-rays or MRI scans (where appropriate) to help diagnose any pathology. Those referred with significant unexplained knee pain should have up to date knee X-rays performed and MRI scan if knee X-ray fails to demonstrate an underlying cause. 

Radiographs: Weight bearing AP (single leg standing) and lateral if:

• New onset of pain older than 50 years
• History of acute trauma, with associated knee swelling
• History of osteoporosis, gout, rheumatological disease
• Painful knee deformity
• Weight loss, past medical history of cancer, night pain, fever longer than 48 hrs.
• Knee joint effusion
• Loose intra-articular body suspected
• Prior to MRI as per protocol.

Ultrasound scan may be indicated if suspicious of extensor mechanism injury

Possible serious pathology. 
Some acute cases e.g. fractures, dislocations, significant soft tissue injuries, bone or joint infections, possible cancer, clearly require urgent referral for specialist assessment and management and can be referred to the fracture clinic via our on-call service.

• Infections
  • Septic arthritis. Acute bacterial septic arthritis is a surgical emergency requiring prompt surgical washout to prevent or limit articular cartilage destruction. Suspected acute infection of a native joint typically presents with severe pain, severely limited movement, pyrexia and systemic upset. Some cases of septic arthritis are clinically less obvious. Acute monoarthritis from crystal arthropathy (gout or pseudogout), an inflammatory arthropathy (RA, reactive arthritis, enteropathic arthritis) or a bad flare up of osteoarthritis may mimic septic arthritis. Where septic arthritis is suspected, referral to the emergency on call registrar (for A&E and ward referrals) or consultant (for GP / primary care referrals) should be made for urgent assessment and likely joint aspiration.
  • Acute Prosthetic Joint Infection/or suspected infection (less than 6 weeks from surgery). Where an infection is suspected and there is a recently implanted joint replacement, antibiotics should not be commenced and emergency referral should be made via our on call orthopaedic consultant (pager 3169). Appropriate management to try to eradicate a potentially serious prosthetic infection may be surgical washout with samples taken to culture any causative organism(s). Antibiotics may compromise the ability to culture any responsible bacteria.
  • Late infections from haematogenous seeding into the prosthetic joint (typically more than two years after surgery) can present acutely. Where there are signs of prosthetic joint infection and symptoms have been present for less than 6 weeks emergency referral to our on call consultant (pager 3169) is indicated for consideration of surgical washout. More chronic haematogenous infections (or possible infections) in a systemically well patient should be referred urgently to the relevant subspecialty. Named referred to the original operating surgeon (if still working locally) may be appropriate. For all late infections (or suspected infections), antibiotics should not be commenced until the patients has been reviewed by or discussed with an orthopaedic consultant.
  • Late Prosthetic Joint Infections (more than 6 weeks from surgery). Low grade infections of a joint replacement from the time of surgery can present at a later stage with a more insidious clinical course. Any infection present for longer than around 4-6 weeks is unlikely to be eradicated with surgical washout and may require more extensive surgical management. Patients with low grade infections may have persistent pain and/or progressive loosening of implants whilst some chronic infections develop a sinus around the surgical scar with leakage of infective fluid which is pathognomonic of deep prosthetic joint infection. Post-operative infections later than six weeks from the time of surgery who are systemically well should be referred urgently to their operating consultant as a named referral. Those with symptoms or signs of systemic sepsis require emergency referral to the on call consultant (pager 3169) (or registrar out-of-hours). Again, any complex cases can be discussed with the on call consultant.
• Extensor mechanism failure. Rupture of the quadriceps tendon or patellar tendon (with inability to straight leg raise and palpable gap mandates urgent surgical repair to restore function and should be referred to the Orthopaedic On-Call Service for admission and emergency surgery on the trauma list. 

Urgent referrals

• An acute knee injury may have been appointed to the fracture clinic, physiotherapy knee clinic or soft tissue knee clinic via Accident & Emergency or our on-call service. Occasionally some knee injuries requiring urgent assessment present to primary care.

Indications for urgent referral to knee service include:

• Where there is suspicion of or possibility of cancer affecting the soft tissues of the knee (sarcoma) with red flag features and/or positive imaging, referrals should be marked as urgent - suspected cancer.
• Fractures around the knee (including osteochondral fractures) should be referred to the fracture clinic
• Significant injury? (feeling of pop/snap, rapid swelling, inability to complete activity?)
• Where the diagnosis is unclear (obese patient, pain limiting assessment) admission for either inpatient imaging (usually ultrasound) or surgical exploration is warranted. (Test - Can’t straight leg raise?)
• Any first time haemarthrosis
• Locked knee/inability to fully extend on passive movement
• Gross laxity on varus/valgus stressing
• Persistent (>3wks) swelling after injury
• A potentially repairable acute peripheral meniscal tear (on MRI)

Routine referrals to Knee Service 

• End-stage osteoarthritis of the knee for consideration of joint replacement. 
• Rheumatoid arthritis and inflammatory arthritis
• Problems with a Knee Replacement
• Unexplained knee pain
• Genu Varum for consideration of Osteotomy (uncommon)

Conditions referred to Knee service that will be vetted to the soft tissue knee clinic include:

• Instability due to previous ligament injury with recurrent giving way despite rehabilitation
  • ACL rupture
  • MCL rupture
  • LCL rupture
  • PCL rupture
• Recurrent patellar dislocations
• Traumatic irreparable and/or chronic meniscal tears with locking
• Mechanical symptoms from a loose body
• Persistent pain from a chondral/osteochondral defect
• Osteochondritis Dissecans
• Swellings around the knee with no red flag features
  • Parameniscal cysts
  • Chronic bursitis
• Unexplained knee pain
  • Rule out hip and/or spinal pathology as a cause of pain
  • Cases of severe unexplained knee pain which cannot be diagnosed with clinical assessment and plain X-rays warrant further investigation 
  • Features of neoplasia (constant pain, worse at night, severe pain, weight loss, history of cancer) and infection (fever, constant pain). Where there is any suspicion of cancer. patients should be referred for urgent X-rays +/- MRI.
  • For any cases of unexplained knee pain MRI is reasonable to look for an underlying structural cause including rarer conditions such as osteonecrosis and synovial sarcoma (rare)
  • We are happy to provide opinion on unexplained knee pain and assist with diagnosis. Where there is no underlying structural cause found on MRI, it is highly unlikely there will be a surgically remediable problem.  

• We do much fewer knee arthroscopies than previously in response to high quality clinical evidence that for the degenerate knee it is no better than sham surgery. 
• Degenerative Meniscal Tears unless there is a large unstable fragment of cartilage with a good history of true locking (recent evidence: surgery no better than leaving alone) - routine referral MSK physiotherapy.
• Knee arthroplasty is usually not appropriate in patients with BMI > 40, and will only be offered for end stage arthritis. Weight loss may reduce need for surgery and is associated with better outcomes and reduced complication rate if surgery proceeds.
• Knee effusion with no history of trauma - refer to Rheumatology.
• Knee instability problems - patients should have completed a 6 month course of MSK physiotherapy prior to referral unless there is an indication for urgent referral.
• Idiopathic adolescent anterior knee pain, patellofemoral joint dysfunction - routine MSK physiotherapy referral 
• Tendinopathies - routine referral MSK physiotherapy
• ITB friction syndrome - refer MSK physiotherapy
• Baker’s cysts - routine referral MSK physiotherapy if problems with knee ROM.
• Patients who have not had adequate conservative management or diagnostic workup. Appropriate clinical work-up and full treatment programme is advised prior to referral. MSK Physiotherapy is first line management for most knee complaints (+/-corticosteroid injections). MSK Physiotherapy colleagues can inject, and request most imaging as necessary if onward referral is required.
• When it is clear that surgery is either not appropriate (e.g the level of arthritis on x-ray is not considered advanced enough to consider knee replacement) or that there is no surgical solution for a problem, referrals may be returned to the referring clinician with an explanation of the decision making and advice to the referrer where appropriate.
• Where there are clear significant risk factors for an adverse outcome after knee replacement, we may send advice back to the referrer explaining why knee replacement is not appropriate.
• Occasionally, referrals have insufficient information to vet accurately or appropriately. Where there is insufficient information to guide referral management, we may ask for further information or investigation to be requested to assess the need for referral.
• Some referrals may be more appropriately seen by rheumatology, or specialist allied health professional services. Where a referred patient may be more appropriately seen by another speciality, the referral may be redirected appropriately

Emergency Referrals
For knee injuries or suspected infection, referral for advice or assessment should be made to the on call Orthopaedic Surgery Registrar via the Ninewells switchboard. Bleep 4561

Suspected Cancer. For assessment / opinion on tumours or possible cancer, we do not have a specialist tumour clinic. Referrals should be made to the appropriate subspecialty clinic according to the location of the tumour or age of the patient (paediatric patients). Where there is a possibility or suspicion of malignancy, the 'urgent suspected cancer' priority option should be selected on SCI Gateway or the written referral marked appropriately.

Outpatient referrals or non-urgent advice via SCI Gateway/Orthopaedic/Knee, flagged as urgent
(suspected cancer), urgent, routine or advice.

Named Referrals to specific consultant or other clinician may be appropriate if the patient has previously been seen by that clinician for the same problem, however an appointment with that consultant cannot be guaranteed. For referrals regarding a new problem, a named referral request cannot be guaranteed.