Rethink investigations and referrals for knee pain, emphasises new standard

Each year, more than 53,500 knee replacements are performed to treat osteoarthritis in Australia¹ and the figure is rising. By 2030, knee replacements are expected to increase by 276%.²

In Australia, osteoarthritis is the most common form of arthritis with around 2.1 million (8.3%) people in the country estimated to be living with the condition in 2022.

Surgery is often seen as an inevitable magic bullet for those who live with pain and disability from osteoarthritis of the knee. But most people can successfully reduce their pain and improve mobility without major surgery and the associated costs, recovery period and potential complications.

To better support people with knee osteoarthritis, the Australian Commission on Safety and Quality in Health Care has released a revised national Standard that outlines the right way to care for this disease, reflecting solid evidence of strong health outcomes without surgery.

Performed at the right time for the right people, surgery can have a dramatic benefit, the commission clarified. However, a significant number of patients remain dissatisfied after joint replacement due to unmet expectations^.3

The ‘poor cousin’

Since the release of the original standard in 2017, studies have reinforced that non-surgical treatments are preferred for most people, the commission noted.

Knee arthroscopy — ‘keyhole’ surgery to examine the joint and remove damaged tissue — is now rarely recommended for osteoarthritis. The procedure is shown not to improve pain or function and saw a dramatic 47% decrease between 2015 and 2022 for people aged over 45 years^.4

While often seen as the poor cousin of treatment options, physical activity and weight management are key. Despite popular misconceptions, exercising is safe and effective when tailored to a person’s needs.

The 2024 Osteoarthritis of the Knee Clinical Care Standard explains best practice care throughout a patient’s journey — in the community by GPs, physiotherapists, exercise physiologists and dietitians, as well as rheumatologists, orthopaedic surgeons and other specialists.

A lever for change

Medical Advisor for the Commission and general practitioner, Dr Phoebe Holdenson Kimura, said the standard was a vital lever for change, to embed the latest research in day-to-day medical practice.

“Our understanding of osteoarthritis and the pathology of the knee joint and soft tissues has changed,” Kimura said.

“There must be a corresponding mindset change in how we both think and talk about osteoarthritis of the knee as a disease, to have a more holistic view of the person.”

The updated standard includes practical communication tips for clinicians on how to talk with patients.

“Let’s avoid language that catastrophises osteoarthritis, including phrases like ‘bone on bone’ and ‘wear and tear’, which suggest we will damage our joints by moving them — that’s simply not true,” Kimura said.

“Non-operative approaches such as physical activity, exercise and weight management are proven to make a big difference to quality of life for most people with knee osteoarthritis. This is great news for patients who can better manage their condition and may avoid or delay knee replacement surgery.”

Kimura said the standard empowered patients to take control and encouraged clinicians to support non-surgical treatments, rather than waiting for surgery or relying solely on pain relief medicines.

“There is an opportunity to shift the conversation to focus on active management and to reduce unhelpful beliefs — such as fear and avoidance of physical activity,” she said.

Osteoarthritis is more common in people aged over 45 years. With Australia’s ageing population, the number of people with knee osteoarthritis increased 126% between 1990 and 2019.⁵

Weight is also a contributing factor, as a person who is overweight has double the risk of developing knee osteoarthritis.

Rethink investigations and referrals

Over the past decade, treatment for knee osteoarthritis has changed, said Gold Coast orthopaedic surgeon Adjunct Professor Christopher Vertullo, who has performed knee surgeries for 20 years.

The Deputy Clinical Director of the Australian Orthopaedic Association National Joint Replacement Registry, and one of the experts involved in reviewing the Standard, said knee surgery should never be seen as a ‘quick fix’ for osteoarthritis.

According to Vertullo, the most important aspect of the revised clinical care standard is the focus on reducing unnecessary imaging, and ultimately, surgery that isn’t needed.

“For most middle-age and older patients with atraumatic onset — where knee pain has come on by itself, without injury — the pain is likely to settle down, and immediate investigations with imaging is not usually required,” he said.

“Patients and healthcare practitioners need to rethink investigations and referrals for knee pain unless they are clinically appropriate.

“In my own practice, about a third of referred patients don’t need to see me, and about 60% of all my patients have had an inappropriate investigation or scan, without any initial management for osteoarthritis. I am having regular conversations about the need to maximise non-surgical management.

“In Australia we have seen a gradual fall in rates of knee arthroscopy. Yet at the same time, we’ve seen rising rates of investigations such as X-rays, MRIs, ultrasounds and CT scans, reduced rates of proper clinical assessment, and lower rates of appropriate management before a patient is referred for surgery.”

Vertullo said the beneficial effects of improved weight management and increased physical activity meant many patients with knee osteoarthritis may never need to see a surgeon or have surgery.

“A patient should only be considered for joint replacement once they have maximised non-operative management as much as possible, and reached a point where their pain is untenable or unmanageable.

“No one should enter surgery lightly. It is fantastic for end-stage osteoarthritis of the knee when someone has severe pain, but for an occasional ache, you are likely to be dissatisfied with the outcome,” he said.

<sup>1. Australian Institute of Health and Welfare. Chronic musculoskeletal conditions: Osteoarthritis. AIHW 2024. https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/osteoarthritis
2. Ackerman et al. BMC Musculoskeletal Disorders. (2019) The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030.
3. Hafkamp, F. J., Gosens, T., de Vries, J., & den Oudsten, B. L. (2020). Do dissatisfied patients have unrealistic expectations? A systematic review and best-evidence synthesis in knee and hip arthroplasty patients. EFORT open reviews, 5(4), 226–240. https://doi.org/10.1302/2058-5241.5.190015
4. Australian Commission on Safety and Quality Health Care analysis of Medicare Benefits Schedule (MBS) Claims data, 2023. Data extraction date 15 March 2023.
5. Ackerman IN, Buchbinder R, March L. Global Burden of Disease Study 2019: an opportunity to understand the growing prevalence and impact of hip, knee, hand and other osteoarthritis in Australia. Intern Med J. 2023 Oct;53(10):1875–82</sup>

Image credit: iStock.com/chanakon laorob