Osteoarthritis refers to a condition where there is joint pain accompanied by functional limitation and reduced quality of life.
It mainly affects people over the age of 45, and is more common in women, people living in areas of high deprivation, and people with obesity. Osteoarthritis is a long-term condition, but it doesn’t always get worse, and symptoms can gradually improve with effective treatment and support. (Versus Arthritis: State of Musculoskeletal Health, 2021)
8.5 million people are living with osteoarthritis in the UK. Source: Global Health Data Exchange, 2019
Our guideline on osteoarthritis recommends that adults aged 45 or over should be diagnosed with osteoarthritis clinically without investigations if they have activity-related joint pain and either no morning joint-related stiffness or morning stiffness that lasts no longer than 30 minutes.
The primary treatments for osteoarthritis are non-surgical, and include lifestyle changes, supportive therapies and medication to relieve pain. In some cases, when other treatments have not helped or the joint pain or functional limitation is severe, surgery can repair, strengthen or replace a damaged joint.
Non-surgical management
After diagnosis of osteoarthritis, people should have an assessment that covers pain, impact on daily activities and quality of life. This assessment helps to support self-management by focusing on individual goals and preferences, allowing healthcare professionals to provide holistic patient-centred advice and support. Self-management is an important area of focus in our quality standard on osteoarthritis.
There is a real opportunity to develop and improve the data we collect on musculoskeletal conditions in primary and community settings, to help us plan and deliver effective integrated care.
Having a clear understanding of what we are doing and its effectiveness is key to developing musculoskeletal services.
4 in 5 people with osteoarthritis have at least 1 other long-term condition, such as cardiovascular disease or depression. Source: Versus Arthritis, State of Musculoskeletal Health, 2021
Before consideration of or referral for joint surgery, we recommend that adults with osteoarthritis should be supported with non-surgical core treatments for at least 3 months. Core treatment options include providing information to support a better understanding of the condition, muscle strengthening and aerobic exercise, and interventions to achieve weight loss for people who are overweight or obese.
These treatments support people to manage their condition and can help to relieve symptoms. Ensuring that they are tried before referral for surgery may reduce unnecessary referrals. Those people who do have surgery are more likely to have better long-term outcomes if core treatments have been given preoperatively.
Implementation of non-surgical treatment options
The Central London Community Health NHS Trust set up a healthy knee group to provide education to people with knee osteoarthritis who have been referred to physiotherapy by their GP. After attending, 77% of people were happy to self-manage their condition and only 10% needed further review with a physiotherapist
The Staffordshire and Stoke on Trent Partnership NHS Trust set up a 6-week programme focusing on personalised education and exercises to improve strength and fitness. After attending this programme, 52% of people reported reduced pain scores and 95% had improvement in at least 1 functional measure.
Surgical management
When a person with osteoarthritis has severe pain that is significantly affecting their life, and other treatments have been explored, they may be referred to an orthopaedic surgeon for consideration of joint surgery. This is usually done on the hip and knee joints.
Knee arthroscopy
Knee arthroscopy is keyhole surgery in which the knee joint is flushed to remove fluid and loose bodies (lavage), or broken-down bone and cartilage (debridement). Our guideline on osteoarthritis recommends that this surgery should only be offered under very limited circumstances; when a person has knee osteoarthritis with a clear history of mechanical locking (as opposed to morning joint stiffness, ‘giving way’ or X-ray evidence of loose bodies). This is based on clear evidence that arthroscopy is not a clinically effective intervention for most people with osteoarthritis.
There has been a significant drive to reduce the number of unnecessary knee arthroscopies done in the NHS. In 2018, NHS England launched the Evidence-Based Interventions (EBI) programme, which uses NICE guidance to identify treatments that are no longer appropriate. The EBI programme aims to reduce the number of inappropriate interventions, to improve the quality of care, and to free up clinical time. Based on our guidance, knee arthroscopy for osteoarthritis is included as a ‘category 1’ intervention, meaning it should not be routinely commissioned or performed.
The number of knee arthroscopies for adults with osteoarthritis has decreased since 2008, when we published guidance recommending limited arthroscopy usage
Conducted between April 2003 and December 2019
Source: NHS Digital, Hospital Episode Statistics
The Getting It Right First Time (GIRFT) Orthopaedics follow-up report shows that there has been a progressive year-on-year reduction in the proportion of knee arthroscopies which are followed by a full knee replacement within a year. This is a clear indication that there has been a reduction in the number of inappropriate knee arthroscopies being done. Since 2014, there have been over 2,900 fewer arthroscopies requiring subsequent knee replacement, resulting in costs savings of £5.9 million.
Joint replacement
Joint replacement surgery is when the knee, hip or other joint is fully or partially replaced with an artificial joint. Osteoarthritis is the main reason for joint replacement surgeries in the UK, although most people with osteoarthritis of the hip or knee will not need surgery.
Osteoarthritis was the sole indication for:
Conducted between April 2003 and December 2019
Source: National Joint Registry Annual Report, 2021
Rehabilitation before and after a joint replacement operation can greatly affect surgical outcomes. Engagement with rehabilitation services before surgery can help prepare people for surgery, increase their ability to manage any complications of surgery, and promote understanding of and engagement with rehabilitation services after surgery. After surgery, prompt self-directed or supervised rehabilitation can reduce the length of stay in hospital, improve surgical outcomes and deliver greater savings.
Our guideline on primary joint replacement recommends that people who have had a primary elective hip, knee or shoulder replacement should be offered rehabilitation by a physiotherapist or occupational therapist. This should be offered on the day of surgery if possible and no more than 24 hours after surgery. Other recommendations cover self-directed rehabilitation before discharge and providing more support if this does not meet the person’s goals.
The 2020 GIRFT Orthopaedics follow-up report highlights that, since the original 2015 GIRFT Orthopaedic report, there has been a recognition from trusts of the need to invest in physiotherapy to improve quality of care, deliver improved patient outcomes, and make long-term savings.
Many trusts are now investing in physiotherapy services. However, there is still room for improvement; 38% of trusts reported that all people having a total knee replacement receive a multidisciplinary assessment before their surgery to determine achievable rehabilitation goals. Similarly, a third of trusts reported that, as routine practice, all people having a full knee replacement have a follow-up with a specialist physiotherapist within 3 weeks to assess postoperative progress. (GIRFT, Orthopaedics follow-up report, 2020)
The cancellation and delay of elective surgeries during the COVID-19 pandemic has had a significant effect on people awaiting joint surgery. NHS England’s Referral to Treatment figures show that the number of people waiting for trauma and orthopaedic surgery increased by 53% from 460,595 in April 2020 to 704,170 in October 2021.
Insight from Zoë Chivers
Long-term management of osteoarthritis requires a holistic approach to providing care. Musculoskeletal conditions are under-recognised in both the undergraduate and postgraduate training, and consequently, GPs often lack confidence in delivering this care. The decision support tools developed by Versus Arthritis and endorsed by NICE are designed to help doctors and patients make informed shared decisions about treatment.
Lack of access to community services, like peer support and mental health services, also makes supporting effective self-management challenging. The increasing prevalence of risk factors like obesity and the impact of COVID-19 means that demand for these services is likely to increase further.