Circle Bedfordshire Musculoskeletal Service:

Transcription

1 Circle Bedfordshire Musculoskeletal Service: Surgical Thresholds for procedures of Low Clinical Value, and management of these conditions within the MSK Service January 2017 This guidance relates to the surgical thresholds for procedures of low clinical value (as determined by the Bedfordshire & Hertfordshire clinical priorities forum and Cambridgeshire and Peterborough Clinical Commissioning Group). It also demonstrates alternative management for patients who do not meet the threshold criteria. The procedures of low clinical value include: Carpal Tunnel Syndrome Dupytrens contracture Elective Total Hip Replacement (THR) Elective Total Knee Replacement (TKR) Ganglions Hallux Valgus Knee arthroscopy Trigger finger Non-acute spinal surgery Shoulder pain (including referral to surgery) Chronic hip pain Pain procedures The flow chart on the next page shows management of these conditions by the MSK service as agreed with Bedfordshire CCG. Please see Appendix for more specific thresholds for each condition. Please note the Fit for OP guidance is currently being reviewed by Bedfordshire CCG and this is likely to result in amendments to these thresholds. Page 1 of 55

2 Circle Bedfordshire Musculoskeletal Services: Management of Procedures of Low Clinical Value Referral received by Circle Bedfordshire MSK Clinical triage by Extended Scope Practitioner Returned to referrer request for more/missing information No Referral with sufficient clinical information? Yes Does not meet the clinical thresholds as set out in this document and no alterative within MSK service Meets the clinical thresholds as set out in this document. Returned to referrer with clinical thresholds for information Accepted and triaged to provider as clinically appropriate Alternatives can be offered. If referrer feels patient meets criteria re-refer and provide more information If referral still rejected OR GP feels patient does not meet criteria but there is a valid reason for needing treatment refer to BCCG exceptions panel; if approved, GP to send back to MSK service with referral and evidence of approval lll Page 2 of 55

3 Management of the low clinical value conditions: Condition/ Procedure Carpal Tunnel Syndrome Dupytrens contracture Elective Total Hip Replacement (THR) GP/ Self Management Nocturnal neutral wrist splint / Steroid Injection Advice to passively stretch finger/ maintain movement Weight loss, adequate analgesia (including NSAIDs), advice to keep active and minimise weightloading e.g. using walking aids, lifestyle adjustment where indicated If for surgical referral, GP to Management in MSK Service?corticosteroid injection Triage to surgery where meets criteria None referrals not meeting surgical threshold will be rejected; Triage to surgery only where meets criteria Triage to Physio / Community MSK if not meeting surgical criteria. Those triaged to surgery will have discussion with Shared Decision Making team: if not meeting criteria / too young / do not want surgery, will be seen in MSK or Page 3 of 55 Summary of Surgical Thresholds (see checklists for more detail) Severe neurological symptoms at presentation: constant numbness or disabling pain with wasting of thenar muscles, and/or weakness of thumb muscles. OR Moderate symptoms (paraesthesia that interferes with activities of daily living or causes constant night waking, and/or reversible numbness and/or pain, perhaps by clenching and unclenching of fist or hand shaking) Has not responded to a minimum of 3 months of conservative management, including a compliant trial of nocturnal neutral wrist splints Consideration of one corticosteroid injection Moderate to severe form of disease with notable functional impairment a) 30 o or more fixed flexion at the metacarpophalangeal joint OR b) 30 o or more fixed flexion at the proximal interphalagneal joint NB: this policy does not cover fast-track referral where there is diagnostic uncertainty. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently. Patient has uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations (e.g. Oxford hip score <20) as defined in Table 1 below. Symptoms refractory to >6 months of nonsurgical management of hip pain due to osteoarthritis, including: Adequate medication optimal tolerated doses of analgesia Physiotherapy (guided exercise and muscle strengthening programmes or supervised physical therapy) but NB: physiotherapy is ineffective in bone-on-bone osteoarthritis Patient education to minimise weight-loading, activity

4 Elective Total Knee Replacement (TKR) arrange X-ray and BMI measurement results to be sent with MSK referral Weight loss, adequate analgesia (including NSAIDs), advice to keep active and minimise weightloading e.g. using walking aids, lifestyle adjustment where indicated If for surgical referral, GP to arrange X-ray and BMI measurement results to be sent with MSK referral referred for physio. If appropriate for onward referral to surgery, offered choice of provider. Triage to Physio / Community MSK if not meeting surgical criteria / if corticosteroid injection to be considered. Those triaged to surgery will have discussion with Shared Decision Making team: if not meeting criteria / too young / do not want surgery, will be seen in MSK or referred for physio. If appropriate for onward referral to surgery, offered choice of provider. modification (avoid impact and excessive exercise) and lifestyle adjustment. Also consider appropriate walking aids +/- home adaptations Where weight may restrict mobilisation post-operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of THR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m 2 should be routinely offered referral to a weight management service to reduce these risks). Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations (e.g. Oxford knee score <20) as defined in Table 1 below Symptoms refractory to >6 months of nonsurgical management of knee pain due to osteoarthritis, including: Adequate medication optimal tolerated doses of analgesia Physiotherapy (guided exercise and muscle strengthening programmes or supervised physical therapy) but NB: physiotherapy may be ineffective in bone-on-bone osteoarthritis with no quadriceps wasting Patient education to minimise weight-loading, activity modification (avoid impact and excessive exercise) and lifestyle adjustment. Also consider appropriate walking aids +/- home adaptations Where weight may restrict mobilisation post-operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of TKR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m 2 should be routinely offered referral to a weight management service to reduce these risks). Please note that patella resurfacing will not be routinely funded as evidence Page 4 of 55

5 Ganglions Hallux Valgus Knee Arthroscopy If not meeting criteria reassure. A proportion resolve spontaneously Lasting benefit of surgery is unclear recurrence rates 1-40% depending on technique and site. Aspiration may be tried in Primary care (request hub support if required) Foot wear advice, simple analgesia, non-surgical treatments e.g. bunion pads, splints, insoles, shields Weight loss, adequate analgesia (including NSAIDs), advice to keep active and minimise weightloading e.g. using walking aids, lifestyle adjustment where indicated GP to provide BMI with MSK referral. None referrals not meeting surgical threshold will be rejected; Triage to surgery only where meets criteria None referrals not meeting surgical threshold will be rejected; Triage to surgery only where meets criteria Triage to Physio / Community MSK if not meeting surgical criteria and no previous treatment. Those triaged to surgery will have discussion with Shared Decision Making team: if not meeting criteria / do not want surgery, usually referred to physio (occasionally to Community MSK) Page 5 of 55 suggests there is no difference in clinical outcomes. Significant skin breakdown, significant nail deformity or has required repeated episodes of drainage caused by distal interphalangeal joint mucous cysts OR Ganglion causes significant functional impairment and/or pain unrelieved by aspiration NB: This policy does not cover fast track referral where there is diagnostic uncertainty. A cystic swelling is likely to be a ganglion. However, a lump which is solid on USS or is not definitely cystic may be malignant. These lumps require MRI scan. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently. Conservative management has failed severe pain or deformity (overriding toes) that causes significant functional impairment (preventing vital work, educational, domestic or carer responsibilities) Completed 6 months of conservative treatment non-smoker or attempted smoking cessation normal BMI or attempted weight loss OR Mechanical locking worsening symptoms non-smoker or attempted smoking cessation normal BMI or attempted weight loss (to normal BMI or at least 10% of body weight) NB this policy does not cover arthroscopy following trauma, septic arthritis (which would warrant referral to orthopaedic on-call team via A&E) or suspected malignancy, which would warrant urgent referral. N.B Arthroscopies for Osteoarthritis (and/or degenerative meniscal tears in patients over 50 will not be routinely funded)

6 Trigger finger Spinal surgery NSAIDs/ analgesia and OTC splints/ Corticosteroid Injection Analgesia If appropriate for onward referral to surgery, and imaging completed, offered choice of provider. See in MSK for corticosteroid injection(s) Triage to Physiotherapy (occasionally MSK) unless meet criteria for surgery Moderate symptoms at presentation: triggering with difficulty actively extending finger/need for passive finger extension OR loss of complete active flexion failure to respond to conservative treatment ( 2 corticosteroid injection) OR Severe symptoms (fixed contracture) that cannot be corrected with any other method OR Corticosteroid treatment is not suitable Lumbar disc conditions, duration >12 weeks, offered non-acute spinal surgery only under the following circumstances: 1. Surgical discectomy (standard or microdiscectomy) in selected patients with sciatica secondary to disc prolapse where conservative management has failed for at least 12 weeks; if radicular pain has not responded to non-invasive treatment after 12 weeks; the patient has been referred to Tier II musculoskeletal assessment service for assessment for spinal surgery or other non-invasive intervention; the patient has lumbar radiculopathy with corresponding intervertebral disc prolapse on magnetic resonance imaging (MRI). 2. Severe spinal stenosis with symptoms of neurogenic claudication and the MRI shows significant canal stenosis 3. Spinal fusion may be considered for nonspecific back pain if severe pain continues despite two years of active rehabilitation, cognitive intervention combined with exercises where available and the patient has been assessed by a specialist using appropriate scans Page 6 of 55 NB this policy does not cover acute back pain conditions such as fracture,

7 dislocation, complications of tumour or infection and/or nerve root or spinal compression responsible for progressive neurological deficit; nor does it cover some of the causes of chronic back pain e.g. osteoporosis and related compression fractures, lumbar spine arthritis, infection, tumour, sagittal imbalance and spinal deformity. Shoulder pain (including referral to surgery) Self-care advice on modifying activities, use of NSAIDs and home exercises. If selfmanagement effective, patients should be referred for physiotherapy. Steroid injections will only be funded for patients whose pain is not controlled by NSAIDs or in whom the use of NSAIDs are contraindicated and other conservative management has failed. NB: in cases where injections are necessary to enable a patient to undergo physiotherapy, these may be used at the time of the first course of physiotherapy. GPs should refer to secondary care directly for red flag patients, i.e. suspected cancer or cauda equina compression Patients with a traumatic injury or dislocation may be referred to Trauma and Orthopaedics. Where an MRA scan/ultrasound has demonstrated evidence of a full thickness rotator cuff tear or significant superior labral anterior-posterior tear (detachment of labrum), shoulder surgery will be funded. For other conditions, before shoulder surgery will be funded, patients should have undergone further conservative management of: 3 months: partial thickness tears or minor superior labral anterior-posterior tears (fraying). 6 months: adhesive capsulitis, impingement syndrome, non-traumatic instability, calcific tendonitis, biceps tendonitis or acromioclavicular or glenohumeral arthritis*. Shoulder arthroscopy will not be funded as a diagnostic tool. * Where there is clear evidence of severe progressive osteoarthritis, patients may be referred before 6 months. Chronic Hip Pain Weight loss, adequate analgesia; simple home exercises Triage to Physiotherapy. Where patient has not responded to Physiotherapy; triage to MSK consider Page 7 of 55 Hip Resurfacing is a low priority treatment and will not be funded without exceptional case panel approval. Other arthroscopic or open hip surgery is a low priority treatment and will not be funded without exceptional case panel approval (including femoro-acetabular impingement, non-acute labral,

8 Pain Procedures Pain management diagnostics. Up to 3 corticosteroid injections will be funded for the treatment of hip osteoarthritis. Corticosteroid injections will be funded for the treatment of hip bursitis (trochanteric or other) as required. Triage to MSK if no diagnostics; if chronic pain diagnosed and no recent change in symptoms triage to pain management. ligamentum teres or abductor tendon tears, greater trochanteric pain syndrome/ trochanteric bursitis and osteoarthritis). Interventions should be part of an MDT package of care and not seen in isolation. Examples of Interventions where evidence is weak: Spinal cord stimulation. Intravenous regional sympathetic blockade with guanethidine. These are only funded in exceptional cases. The CCG will only fund: lumbar transforaminal and caudal epidural injections for patients with radicular pain due to herniated disc (sciatica) when the following criteria have been met: The patient has radicular pain (below the knee for lower lumbar herniations; into the anterior thigh for upper lumbar herniations) consistent with the level of spinal involvement OR there is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise positive between 30o and 70o positive femoral tension sign) Symptoms persist despite some nonoperative treatment for at least 3 months (e.g. analgesia, physiotherapy). Further Epidural injections should only be provided as part of a comprehensive pain management programme. Facet joint injections Therapeutic The CCG will fund medial branch blocks for the management of cervical, thoracic and lumbar back pain as specified below: All conservative management options, (physiotherapy, exercise, pharmacotherapy Page 8 of 55

9 Page 9 of 55 including analgesia) have been tried and failed And the pain has resulted in moderate to significant impact on daily functioning The treatment of facet joint pain is provided as part of a comprehensive pain management programme Further facet joint injections will only be funded if the initial facet joint injection has had a proven therapeutic benefit and the patient is not suitable for Thermal Radiofrequency Denervation (RFD) or a Pain Management Programme (PMP). For those who are not suitable for RFD or PMP (patients with multiple co morbidities; cardiological and or respiratory dysfunction; cardiac pacemaker or other nerve stimulator; frail patients; elderly patients), up to two injections per year will be funded in line with the Pain Management Pathway for Chronic Facetal Pain. Intra articular injections will only be funded according to the criteria above. Note: (diagnostic facet joint injections used by spinal surgeons as part of a diagnostic pathway prior to making a decision to proceed to surgery will be funded). Radiofrequency facet joint denervation of the medial branch of the dorsal rami of the lumbar and cervical facet joints (medial branch neurotomy) will be funded in the following circumstances: Patients aged over 18 Non-radicular lumbar (all levels) or cervical (C3-4 and below) facet joint pain. Failure of a one year trial of non-invasive therapy, such as medication and physiotherapy. One anaesthetic diagnostic block, which must be of the medial branch of the dorsal rami innervating the target facet joint. A significant reduction in pain following the block during activities that normally generate pain should be demonstrated and recorded. The pain relief must be consistent with the expected duration of the anaesthetic block. All procedures must be performed under fluoroscopy (x-ray guidance). NICE Guidance ID CG 88 on Low Back Pain iv indicates that radiofrequency facet joint denervation is not recommended for those

10 Page 10 of 55 with back pain of less than a year s duration. Thermal radiofrequency denervation is provided as part of a comprehensive Pain Management Programme (PMP). Cryoneurolysis or laser denervation will not be funded. Up to four facet joint denervation s on one occasion (one treatment episode) will be funded.

11 Classification of Pain Levels and Functional Limitations Table (to be used in conjunction with THR and TKR guidelines) Table 1: Classification of surgical criteria Level of pain Slight Moderate Intense Severe Functional limitations Definition Sporadic Pain. Pain when climbing and descending stairs. Allows daily activities to be carried out (those requiring great physical ability may be limited). Medication: Aspirin, Paracetamol or NSAIDs (Non Steroidal Anti- Inflammatory Drugs) to control pain with no/few side effects. Occasional pain. Pain when walking on level surfaces (half an hour, or standing). Some limitation of daily activities. Medication: Aspirin, Paracetamol or NSAIDs to control pain with no/few side effects. Pain of almost continuous nature. Pain when walking short distances on level surfaces or standing less than half an hour. Activities of daily living (ADL) * significantly limited. Continuous use of NSAID for treatment to take effect. Requires the sporadic use of support systems (walking stick, crutches). Continuous pain. Pain when resting. Activities of daily living * significantly limited constantly. Continuous use of analgesics-narcotics/nsaids with adverse effects or no response. Requires more constant use of support systems (walking stick, crutches). Definition Functional capacity adequate to conduct normal activities and self-care. Minor Walking capacity of about one hour. No aids needed. Functional capacity adequate to perform only a few or none of the normal Moderate activities and self-care. Walking capacity of about one half hour. Aids such as a cane/walking stick are needed. Largely or wholly incapacitated. Severe Walking capacity of less than half an hour or unable to walk or bedridden. Aids such as a cane, a walker or wheelchair are required. * ADL includes activities such as meal preparation, laundry, housekeeping, shopping, using the phones, driving or using public transport. Useful site for further information for GPs and patients: Page 11 of 55

12 Bedfordshire Musculoskeletal Services: Procedures of Low Clinical Value Appendix These are checklists for each of the MSK procedures of low clinical value based on the Cambridgeshire and Peterborough Clinical Commissioning Group. Carpal Tunnel Syndrome (CTS) Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria patients should meet the following criteria: OR Severe neurological symptoms at presentation: constant numbness or disabling pain with wasting of thenar muscles, and/or weakness of thumb muscles. Moderate symptoms (paraesthesia that interferes with activities of daily living or causes constant night waking, and/or reversible numbness and/or pain, perhaps by clenching and unclenching of fist or hand shaking) Has not responded to a minimum of 3 months of conservative management, including a compliant trial of nocturnal neutral wrist splints. Consideration of one corticosteroid injection. Patient is a non-smoker OR Patient has been advised of the surgical and post-surgical risks associated with smoking, referred to a smoking cessation service where appropriate and attempted to stop smoking 8 to 12 weeks before the operation. tick box(s) as appropriate Procedure needed to be performed outside the policy criteria. Please give clinical indication: Page 12 of 55

13 Definition: Carpal Tunnel Syndrome (CTS) is a condition characterised by attacks of pain, numbness or tingling in the distribution of the median nerve (thumb, index, middle and half of ring finger). It is caused by compression of the median nerve as it passes under the ligament that lies across the front of the wrist. 1 Policy criteria: The CCG will ONLY fund Carpal Tunnel Surgery in patients diagnosed with Carpal Tunnel Syndrome according to the following criteria: The patient has severe neurological symptoms at presentation, for example altered sensation, muscle wasting or weakness of thenar abduction. OR The patient has moderate symptoms as defined below has not responded to a minimum of 3 months of conservative management, including local corticosteroid injections and a compliant trial of nocturnal neutral wrist splints. Classification for Severity of Carpal Tunnel Syndrome: 2 Mild: Intermittent paraesthesia with or without pain that may be nocturnal, or occurs with a certain hand position. Moderate: Paraesthesia that interferes with activities of daily living or causes constant night waking. And/Or reversible numbness and/or pain (perhaps by clenching and unclenching of fist or hand shaking). Severe: Constant numbness or disabling pain with wasting of thenar muscles. And/Or weakness of thumb muscles (Abductor Pollicis Brevis and Opponens Pollicis). Note: Patients who smoke should have attempted to stop smoking 8 to 12 weeks before the operation to reduce the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. 3, 4 Rationale and Evidence Untreated Carpal Tunnel Syndrome has been shown to resolve or significantly improve in up to 49% of cases. 5 Non-surgical treatment, including oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation show short-term benefit compared with placebo or other non-surgical interventions. 6 Conservative treatment is preferred in mild to moderate cases and surgical treatment is mainly applied in severe cases including nerve denervation. Surgical treatment is indicated in cases where initial conservative management has failed. 7 Corticosteroid injection has been shown to be effective at one month, but the effect decreases by 30% at one year. 8 Local corticosteroid injection is effective in relieving symptoms at one month and is more effective than oral steroids. 9 When steroid injections were compared to splinting, injections were not as effective at one year while splints worn every night were shown to be effective for symptom relief and nerve conduction. 10 Injected steroids have been compared to surgery - one study showed greater improvement in the steroid group for nocturnal paraesthesia at three months, but equivalence at 6 and 12 months 11 whilst another study showed greater symptomatic improvement with surgery at 20 weeks. 12 Another review showed surgery is better than splinting for symptom relief at three months and one year. 13 One particular study showed improved outcomes with surgery at 3 months and 18 months. 41% of the splinting group had undergone surgery by 18 months. 14 Page 13 of 55

14 In terms of which surgery to perform, a Cochrane Review found no strong evidence for replacement of standard open carpal tunnel release (OCTR) by alternative surgical procedures although it reports that endoscopic carpal tunnel release may enable people to return to work and resume daily life activities on average one week earlier than OCTR. 15 Estimated number of people affected: Annual incidence of 139 cases per 100,000 females and 67 per 100,000 males. 16 CTS is more common in middle age (older than 40 years) 17 and in women (during pregnancy and menopause). 1 References: 1. Clinical Knowledge Summary (Sept 2012) [Online] Available from: 2. British Society for Surgery of the Hand (2011) BSSH Evidence for Surgical Treatment (BEST): Carpal Tunnel Syndrome (CTS) [Online] Available from: 3. C Furlong. Preoperative Smoking Cessation: A Model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A report by London Health Observatory. September S Hajioff, M Bhatti. Pre-operative smoking cessation therapy in NCL. A case of short-term gain for long-term gain? 5. Padua L, Padua R, et al. (2001) Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study. Neurology Jun 12;56(11): O Connor D, et al. (2003). Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD DOI: / CD Huisstede BM, et al. (2010). Carpal Tunnel Syndrome. Part II:Effectiveness of Surgical Treatments- A Systematic Review. Arch Phys Med Rehabil 2010; Dammers J, et al. (1999). Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial BMJ : Marshall S C, et al. (2007) Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD DOI: / CD pub Sevim S, et al. (2004). A Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci Jun;25(2): Hui A, et al. (2005). A randomised controlled trial of surgery vs steroid injection for carpal tunnel syndrome Neurology, June 28, 2005; 64(12): Ly-Pen D, Andreu J L, et al. (2005). Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomised, open, controlled clinical trial. Arthritis Rheum 2005;52: Verdugo R J, et al. (2008). Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane, Database of Systematic Reviews 2008, Issue 4. Art. No.: CD DOI: / CD pub Gerritsen A A, et al. (2002). Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomised controlled trial. JAMA 2002 Sep 11;288(10): Scholten R, et al. (2007). Surgical treatment options for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4.Art.No.:CD DOI: / CD pub3. Page 14 of 55

15 Dupytrens Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria patients should meet the following criteria: Note: The policy and this referral proforma do not cover fast track referral where there is diagnostic uncertainty. In particular any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently. Moderate to severe form of disease with notable functional impairment 30 o or more fixed flexion at the metacarpophalangeal joint OR 30 o or more fixed flexion at the proximal interphalagneal joint Patient is a non-smoker OR Patient has been advised of the surgical and post-surgical risks associated with smoking, referred to a smoking cessation service where appropriate and attempted to stop smoking 8 to 12 weeks before the operation. tick box(s) as appropriate Procedure needed to be performed outside the policy criteria. Please give clinical indication:... Definition: Dupuytren s Contracture is defined as a benign proliferative (rapidly growing) disease that occurs in the fascia of the palms and fingers leading to the formation of nodules, cords and resulting in contractures. 1 A clawing deformity of the fingers develops, particularly the little and ring fingers. Policy criteria: The CCG will ONLY fund the surgical treatment of Dupuytren s Contracture according to the following criteria: The patient has a moderate to severe form of disease as defined below. Classification for Severity of Dupuytren s Contracture: 2 Mild: No functional impairment Contractures less than 30 o at metacarpophalangeal joints (MCPJ) Moderate: Notable functional impairment o fixed flexion at the MCPJ and less than 30 o at the proximal interphalagneal joint (PIPJ) Severe: Fixed flexion greater than 60 o at the MCPJ and greater than 30 o at the PIPJ Page 15 of 55

16 Note 1: Patients who smoke should have attempted to stop smoking 8 to12 weeks before the operation to reduce the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. 3, 4 Note 2: This policy does not cover fast track referral where there is diagnostic uncertainty. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently. Rationale and Evidence: Non-surgical treatments such as Clostridial collagenase injection, Percutaneous needle fasciotomies (PNF) and Radiation Therapy have been shown to have some benefit, but there is no clear evidence that outcomes are better than surgical interventions. 5-7 It is suggested that surgery should be performed on an affected MCPJ if the contracture is 30 or greater and if there is involvement of the PIPJ. 8 A retrospective audit indicated that surgery for Dupuytren s disease is successful in achieving full or almost full correction in 75% of cases, but recurrence rate in cases ranged 9, 10 from 26-80%. The National Institute for Health and Clinical Excellence (NICE) reviewed evidence for the practice of percutaneous needle fasciotomies (PNF) as a treatment option - it was shown to not be as effective in preventing recurrence as surgery, but is a good option because low complication profile allowed the procedure to be repeated. 11 NICE guidelines on Radiation Therapy state that there is no strong evidence for efficacy yet, but there are no concerns about safety at the moment and should only be used by experienced senior clinicians. 12 Dupuytren s Contracture is common and the prevalence ranges from % in the UK, varying with geographical location. The disease more commonly affects white people of European descent, men and the elderly. 13 Estimated number of people affected: Dupuytren s Contracture is common and the prevalence ranges from % in the UK, varying with geographical location. The disease more commonly affects white people of European descent, men and the elderly. 13 References: 1. McGrouther D A. (1998). Dupuytren s contracture. In D P Green, R N Hotchkiss and W C Pederson (Eds) Operative H Surgery, Vol 1, 4th edition. New York: Churchill Livingstone, British Society for Surgery of the Hand (2010) BSSH Evidence for Surgical Treatment (BEST): Dupuytren s contracture [Online] Available from: 3. C Furlong. Preoperative Smoking Cessation: A Model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A report by London Health Observatory. September S Hajioff, M Bhatti. Pre-operative smoking cessation therapy in NCL. A case of short-term gain for long-term gain? 5. Badalamente M A, Hurst L C. (2000). Enzyme injection as nonsurgical treatment of Dupuytren's disease. J Hand Surg [Am] 2000: 25; Foucher G, Medina J, Navarro R. (2003). Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br. Oct 2003;28(5): Rayan G M. (2008). Nonoperative Treatment of Dupuytren's Disease. J of Hand Surgery[Am].Volume 33, Issue 7, September 2008, Lee S, Baytion M. (2006). Dupuytren contracture. E-Medicine. December Page 16 of 55

17 9. Dias J J, Braybrooke J. (2006). Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg [Br] Oct;31(5): Epub 2006 Jul Hurst L C, Badalamente MA. (1999). Nonoperative treatment of Dupuytren's disease. Hand Clin 1999 Feb;15(1): NICE guidelines 2004 for Needle Fasciotomy in Dupuytren s Contracture (reviewed in 2011) NICE guidelines 2010 for Radiation therapy for early Dupuytren's disease (reviewed in 2011) Clinical Knowledge Summaries- Dupuytren s Disease (May 2010). [Online] Available from: Page 17 of 55

18 Total Hip Replacement Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum This policy covers referrals for primary elective total hip replacement (THR). This policy does not affect criteria for Immediate / Urgent Referral to Orthopaedic Services in respect of: Evidence of infection in the hip joint. Conditions (such as AVN-avascularnecrosis) leading to a rapid deterioration in the joint where delay to treatment would be unreasonable. The CCG will ONLY fund referral for consideration of THR in patients meeting the following criteria. tick box(s) as appropriate The initial non-surgical (conservative) management of hip pain due to osteoarthritis has been provided for at least 6 months, including: Medication (eg adequate doses of non-steroidal antiinflammatory drugs (NSAIDs) and analgesics). Physiotherapy (guided exercise and muscle strengthening programmes or supervised physical therapy). Patient education (to minimise weight-loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment. Symptoms are refractory to at least 6 months of conservative management as above. Patient has uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations as defined in Table 1 below. Where weight may restrict mobilisation post operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of THR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m 2 should be routinely offered referral to a weight management service to reduce these risks). Patient is a non-smoker OR Patient has been advised of the surgical and post-surgical risks associated with smoking, referred to a smoking cessation service where appropriate and attempted to stop smoking 8 to 12 weeks before the operation. Page 18 of 55

19 Procedure needed to be performed outside the policy criteria. Please give clinical indication:... Definition: This policy covers referrals for primary elective I total hip replacement (THR) I. Total hip replacement (THR) generally involves removal of the head of the femur (thigh bone) and its replacement with a metal or ceramic prosthesis that fits into the remaining bone. The ball end of the artificial femur then fits into a cup-like socket (acetabular cup) that is installed in the patient s pelvis. Policy: The CCG will ONLY fund referral for consideration of THR in patients meeting the following criteria. It is presumed that all referrals meet these criteria prior to referral unless exceptional, in which case the referral should document explicitly the reason for exceptional circumstances. 1. Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations which have failed a reasonable period of maximal conservative treatment (often>3/12) as defined in Table 1 above (*Oxford hip score < 20 may guide the referring clinician however should not be considered an absolute) 2. Symptoms refractory to at least 6 months conservative management for the condition. (*Oxford Hip Score PRIOR CONSERVATIVE MANAGEMENT MUST INCLUDE ALL OF THE FOLLOWING: Medication o The patient should be taking Optimal tolerated doses of analgesia. Patients should have gained an understanding of their correct uses (Paracetamol, NSAIDs or Opioid analgesics). Physiotherapy o NICE core treatments of either guided exercise and muscle strengthening programmes or of supervised physical therapy must have been given. Note: Physiotherapy is ineffective in bone on bone osteoarthritis. Patient Education and Orthosis o Patient education such as elimination of damaging influence on hips (by reducing weight loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment. o Patients must have been advised about, and/or assessed for, clinically appropriate walking aids and home adaptations. Page 19 of 55

20 Lifestyle improvement is paramount prior to major surgery o It is strongly advised to reduce BMI to less than 35 kg/m 2 as this may reduce complications and improve outcomes. Patients with a BMI greater than 35 kg/m 2 should be routinely offered referral to a weight management service to reduce these risks. o Patients who smoke should have attempted to stop smoking 8 to 12 weeks before referral to reduce the risk of surgery and post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. Patients (and carers as appropriate) expectations of surgery, and the likely degree of additional benefit that may be obtained from surgery compared with continuing conservative management, must have been discussed in primary/intermediate care. Patients must have been given an opportunity in primary/intermediate care to complete the Decision Aid tool on This policy does not affect criteria for Immediate / Urgent Referral to Orthopaedic Services in respect of: Evidence of infection in the hip joint. Conditions (such as AVN-avascular necrosis) leading to a rapid deterioration in the joint where delay to treatment would be unreasonable. Rationale and evidence: Purpose of THR and patient selection NICE IPG 363 states that current evidence on the safety and efficacy of minimally invasive total hip replacement appears adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit. Patient selection should be done by surgeons and their teams who can offer both conventional and minimally invasive total hip replacement. Morbidly obese patients have a 65.5% increase in the revision rates for THR versus the normal BMI group ( ) 9. Numbers of people affected: The prevalence of all cause hip disease severe enough to require surgery has been estimated at 15.2 per 1,000 people aged 35 to 85 years of age 12. It has been estimated, based on radiographic evidence, that between 10% and 25% of people over the age of 55 have osteoarthritis of the hip. Symptomatic hip osteoarthritis has been estimated to affect between 0.7% and 4.4% of adults. References: 1. Ipswich and East Suffolk CCG Low Priority Procedure- Policy T18a: Hip Replacement. January National Institute of Clinical Excellence. Primary Care Referral Guidelines for Common Conditions. NICE 2003; London. 3. National Institute of Clinical Excellence. CG59 Osteoarthritis. February Horizon Scan on Hip Replacement Surgery. ECRI Evidence-based Practice Centre Agency for healthcare Research and Quality.USA December 22, National Institute of Clinical Excellence. Primary care referral guidelines for common conditions. NICE 2003; London. 6. National Institute of Clinical Excellence. Minimally invasive total hip replacement. NICE IPG 363; Page 20 of 55

21 7. The Musculoskeletal Services Framework A joint responsibility: doing it differently. Department of Health, set/dh_ pdf 8. Lübbeke A, Stern R, Garavaglia G, Zurcher L and Hoffmeyer P. Differences in outcomes of obese women and men undergoing primary total hip arthroplasty. Arthritis and Rheumatism, 2007; 57: Culliford D, Maskell J et al. A population-based survival analysis describing the association of BMI on time to revision for total hip and knee replacement: results from the UK GPRD. BMJ open National Institute of Clinical Excellence and National Collaborating Centre for Primary Care. Obesity: the prevention, identification, assessment and management of overweight and obesity in adults and children. NICE December 2006; London Azodi O S, Bellocco R, Eriksson K and Adami J. The impact of tobacco use and body mass index on the length of stay in hospital and the risk of post-operative complications among patients undergoing total hip replacement. Journal of Bone and Joint Surgery British, 2006; 88: Furlong C. Preoperative Smoking Cessation: A model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A Report by the London Health Observatory, NICE Guidance on the use of metal on metal hip resurfacing arthroplasty. Technology Appraisal Guidance No 44, NICE guidance on selection of Prostheses for Primary Total Hip Replacement. Technology Appraisal Guidance No 02, Quintana J M, Arostegui I, Azkarate J, Goenaga I, Elexpe X, Letona J and Arcelay A. Evaluation of explicit criteria for total hip replacement. Journal of Clinical Epidemiology, 2000; 53: Dawson J, Fitzpatrick R, Fletcher J and Wilson R. Osteoarthritis Affecting the Hip and Knee. In Health Care Needs Assessment: The epidemiologically based needs assessment reviews, Second Edition, Volume 1. Editors; Stevens A, Raftery J, Mant J and Simpson S. Radcliff, 2004; Radcliffe Publishing Oxford and San Francisco. Page 21 of 55

22 Total Knee Replacement Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum This policy covers referrals for primary elective total knee replacement (TKR) to replace some or all of the components of the knee joint with a synthetic implant, and repair damaged weight bearing surfaces. The policy does not affect criteria for Immediate/Urgent Referral to Orthopaedic Services in respect of: Evidence of infection in the knee joint. Symptoms indicating a rapid deterioration in the joint. Persistent symptoms that are causing severe disability. The CCG will ONLY fund referral for consideration of TKR in patients meeting ALL the following criteria. tick box(s) as appropriate Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations (eg *Oxford knee score <20) as defined in Table 1 above. Evidence of radiological features of disease; severe, moderate or mild if functional issues are severe enough The initial non-surgical (conservative) management of knee pain due to osteoarthritis has been provided for at least 6 months, including: Medication: Optimum tolerated doses of analgesic (Paracetamol, NSAIDs or Opioid analgesics). Intra-articular corticosteroid injections should be considered as an adjunct to analgesia. Physiotherapy: NICE core treatments of either guided exercise and muscle strengthening programmes or of supervised physical therapy. Patient Education: such as elimination of damaging influence on knees (by reducing weight loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment; advice about, and/or assessment for, clinically appropriate walking aids and home adaptations. Symptoms are refractory to at least 6 months of conservative management as above. Where weight may restrict mobilisation post operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of TKR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m 2 should be routinely offered referral to a weight management service to reduce these risks). Patient is a non-smoker. OR Patient has been advised of the surgical and post-surgical risks associated with smoking, referred to a smoking cessation Page 22 of 55

23 service where appropriate and attempted to stop smoking 8 to 12 weeks before the operation. (*Oxford Knee Score Procedure needed to be performed outside the policy criteria. Please give clinical indication:... Definition: This policy covers referrals for primary electivei total knee replacement (TKR)i to replace some or all of the components of the knee joint with a synthetic implant, and repair damaged weight bearing surfaces. Policy: The CCG will ONLY fund referral for consideration of TKR in patients meeting the following criteria. It is presumed that all referrals meet these criteria prior to referral unless exceptional in which case the referral should document explicitly the reason for exceptional circumstances. 1. Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations which have failed a reasonable period of maximal conservative treatment (often>3/12) as defined in Table 1 above (Oxford knee score < 20 may guide the referring clinician however should not be considered an absolute) 2. Symptoms refractory to at least 6 months conservative management for the condition. PRIOR CONSERVATIVE MANAGEMENT MUST INCLUDE ALL OF THE FOLLOWING Medication o Optimum tolerated doses of analgesic should be used and patients should have gained an understanding of how to use oral or topical analgesics (Paracetamol, NSAIDs or Opioid analgesics). o Intra-articular corticosteroid injections should be considered as an adjunct to analgesia. Physiotherapy o NICE core treatments of either guided exercise and muscle strengthening programmes or of supervised physical therapy must have been given. Note: Physiotherapy may be ineffective in bone on bone osteoarthritis with no quadriceps wasting. Patient Education and Orthosis Page 23 of 55

24 o o Patient education such as elimination of damaging influence on knees (by reducing weight loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment. Patients must have been advised about, and/or assessed for, clinically appropriate walking aids and home adaptations. Lifestyle improvement is paramount prior to major surgery o It is strongly advised to reduce BMI to less than 35 kg/m 2 as this may reduce complications and improve outcomes. Patients with a BMI greater than 35 kg/m 2 should be routinely offered referral to a weight management service to reduce these risks. o Patients who smoke should have attempted to stop smoking 8 to 12 weeks before referral to reduce the risk of surgery and post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. Patients (and carers as appropriate) expectations of surgery, and the likely degree of additional benefit that may be obtained from surgery compared with continuing conservative management, must have been discussed in primary/intermediate care. Patients must have been given an opportunity in primary/intermediate care to complete the Decision Aid tool on The policy does not affect criteria for Immediate/Urgent Referral to Orthopaedic Services in respect of: Evidence of infection in the knee joint. Symptoms indicating a rapid deterioration in the joint. Persistent symptoms that are causing severe disability. Rationale and evidence: Purpose of TKR and patient selection TKR is most commonly performed for knee joint failure caused by osteoarthritis (OA); other indications include rheumatoid arthritis (RA), juvenile rheumatoid arthritis, osteonecrosis and other types of inflammatory arthritis. The aims of TKR are relief of pain and improvement in function. TKR can be very successful for selected patients with over 90% of TKRs still in place and functioning well at 10 to 15 years after surgery. Optimum selection of patients is uncertain and conservative management including supervised/group exercise and physical therapy is effective for the majority affected by osteoarthritis. Numbers of people affected: The prevalence of symptomatic knee osteoarthritis has been estimated at 6.1% of people aged over 30 years and 7.5% of people aged over 55. It has been estimated, based on radiographic evidence, that between 14% and 34% of people over the age of 55 have osteoarthritis of the knee. Knee osteoarthritis is strongly associated with obesity and gender (chiefly affecting women) and is related to types of work that involve frequent squatting. References: 1. Bedfordshire and Hertfordshire Priorities Forum Statement Number 33: Referral criteria for patients from primary care presenting with knee pain due to osteoarthritis and clinical threshold for elective primary knee replacement surgery, February Ipswich and East Suffolk CCG Low Priority Procedure- Policy T18b: Knee Replacement. January Page 24 of 55