LOW PRIORITY PROCEDURE - Policy T18a Hip replacement Policy author: NHS Suffolk Public Health Team Policy start date: June 2007 (formally T9) Revision date: January 2011 Review date: January 2013 Referral Criteria for Hip Replacement The NHS Suffolk (Suffolk PCT) will only fund hip replacement for osteoarthritis when conservative measures have failed (listed below) and the following criteria have been met: - Intense to severe persistent pain (defined in table one) which leads to severe functional limitations (defined in table two), or - Minor or moderate functional limitation (defined in table two) affecting the patients quality of life despite 6 months of conservative measures* Exceptions include: a. Patients whose pain is so severe and/or mobility is compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this. b. Patients in whom the destruction of their joint is of such severity that delaying surgical correction would increase the technical difficulties of the procedure. *Conservative measures: 1. Weight reduction. It is strongly advised to reduce BMI 35. A BMI >35 does not preclude referral but all reasonable attempts should be made to reduce the patients weight level suitable for surgery as a higher BMI increases complication rates, increases long-term failure of TKR, increased risks of bleeding and post-operative thrombo-embolism. 2. Oral/topical NSAIDS and paracetamol based analgesics (COX-2 Inhibitor of NSAIDS). Opiod analgesics can be used effectively if paracetamol or NSAIDS are ineffective or poorly tolerated. 3. Patient education such as elimination of damaging influence on hips, activity modification (avoid impact and excessive exercise), good shock-absorbing shoes and lifestyle adjustment.
LOW PRIORITY PROCEDURE - Policy T18b Knee replacement Policy author: NHS Suffolk Public Health Team Policy start date: June 2007 (formally T9) Revision date: January 2011 Review date: January 2013 Referral criteria for Knee Replacement The NHS Suffolk (Suffolk PCT) will only fund knee replacement for osteoarthritis when conservative measures have failed (listed below) and the following criteria have been met: - Intense to severe persistent pain (defined in table one) which leads to severe functional limitations (defined in table two), or - Minor or moderate functional limitation (defined in table two) affecting the patients quality of life despite 6 months of conservative measures* Exceptions include: c. Patients whose pain is so severe and/or mobility is compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this. d. Patients in whom the destruction of their joint is of such severity that delaying surgical correction would increase the technical difficulties of the procedure. *Conservative measures: i. Weight reduction. It is strongly advised to reduce BMI 35. A BMI >35 does not preclude referral but all reasonable attempts should be made to reduce the patients weight level suitable for surgery as a higher BMI increases complication rates, increases long-term failure of TKR, increased risks of bleeding and post-operative thrombo-embolism. 2. Oral/topical NSAIDS and paracetamol based analgesics (COX-2 Inhibitor of NSAIDS). Opiod analgesics can be used effectively if paracetamol or NSAIDS are ineffective or poorly tolerated. 3. Intra-articular corticosteroid injections should be considered as an adjunct to core treatment for the relief of moderate to severe pain 4. Patient education such as elimination of damaging influence on knees, activity modification (avoid impact and excessive exercise), good shock-absorbing shoes and lifestyle adjustment. 5. Physiotherapy as clinically appropriate, including exercise therapy as well as physical measures such as ultrasound, acupuncture, traction, application of heat/cold, muscle stimulation, electrotherapy, stretching/walking. 6. Orthosis. Advice on walking aids, home adaptations and general counselling as regards to the potential benefits of joint replacement. Rationale behind the policy decision Guidance from NICE, musculoskeletal services framework from the Department of Health; GP training Network and the National Institute of Health Consensus panel suggests 1-4 :
- Common MSK pain including knee pain ideally should be managed in primary care. - Primary care practitioners need direct access to orthosis, therapy, dietetics and health promotion services. - Primary care management should seek to maximize the benefits of surgery and minimize complications when surgery is necessary. The development and assessment of guidelines as above for primary care physicians and others make a rapid assessment of the severity and impact of knee OA 4. A study 5 followed up morbidly obese post-op total knee replacements of a 5-year period compared to a control group and found the morbidly obese to have greater earlier complication rates and a notably 5-year survival of their knee replacement with loosening of the tibial component. Another study 5 partitioned the obesity groups to 30-35 and 35+; these patients had undergone a total knee replacement and it was shown that wound infection was more likely in the35+ group. Noted that for every 1kg/mg increase in BMI; this increases the risk of infection by 8% 15. There is also evidence in the published reports to support a correlation between obesity and complications following hip replacement surgery. Obesity has been found to be a specific risk factor for joint infection after total hip replacement 16, 17, 18. A meta-analysis of 16 controlled trials 9 found individual exercise and self-management had a moderate but clinically significant psychological effect and positive contribution to the patient s emotional well being. A Cochrane review 19 found that patients wearing an orthosis were found to have significantly less pain and better function than the control group. Studies have shown manual therapy, individualised or group therapy to reduce pain and improve function significantly 3, 20,21. Intra-articular injections have been shown to significantly reduce pain 2-3 weeks after injections. According to the American Academy of Orthopedic Surgeons, intra-articular injections are recommended for no more than short term use only 22. An Oxford hip/knee score of 29 indicates moderate to severe hip/knee arthritis 23. References 1. NICE. Primary care referral guidelines for common conditions 2003; London 2. National Institute of health. Concensus development program. Dec 2003 3. British Orthopaedic Association. Total knee replacement. A guide to best practice. 2001 4. The musculoskeletal services framework A joint responsibility: doing it differently. Department of Health. 2006. 5. Knee replacement surgery for osteoarthiritis: effectiveness, practice variations, indications and possible determinants of utilization. Rheumatology 1999;28:73-83. P Dieppe, H-D. Basler, J. Chard, P. Croft, J Dixon, M Hurley, S. Lohmander and H. Raspe. 6. Amin, A. K., Clayton, R. A. E., Patton, J. T., Gaston, M., Cook, R. E., and Brenkel, I. J. Total knee replacement in morbidly obese patients. results of a prospective, matched study. J Bone Joint Surg Br 88, 10 (Oct 2006), 1321-1326. 7. Namba, R., Paxton, L., Fithian, D., and Stone, M. Obesity and perioperative morbidity in total hip and total knee arthroplasty patients. J Arthroplasty 20(7) Supplement 3 (2005), 46-50. 8. Patel, V. P., Walsh, M., Sehgal, B., Preston, C., DeWal, H., and Cesare, P. E. D. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 89, 1 (Jan 2007), 33-38.
9. 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: 327-334. 10. 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. 11. Azodi OS, 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: 1316-1320. 12. Braces and Orthosis for treating osteoarthritis of the knee. Cochrane Database Systemic reviews. 2005;1 CD004020. Brouwer RW, van Raaij TM, Jakma TT. 13. The effect of manual therapy knee protocol on osteoarthritis knee pain: a randomised control trial. J Can Chiropr Assoc. 2008; 52@229-242. Pollard H, Ward G, Hoskins W, Hardy K. 14. Do exercise and self management interventions benefit patients with osteoarthritis of knee? A metanalytic review. J Rheumatol 2006; 33:744-756. Devos-Somby L, Crocan T, Roesch SC 15. Intra-articular corticosteroid for treatment of osteoarthritis of the knee. Cochrane Database Syst Rev. 2006;2 CD005328 Bellamy N, Cambell J, Robinson V, et al. 16. Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996 Mar;78(2): 185-90 17. NICE referral guidelines 2001 osteoarthritis of the knee 18. Orthopoedic referral guidelines. www,gp-training.net/rheum/orthoref.htm 19. Arthroplasty of the knee in the obese patients with osteoarthritis. 2007 National Knowledge Week on Osteoarthritis 20. The Epidemiology, Etiology, Diagnosis and Treatment of Osteoarthritis of the Knee. Dtsch Arztebl int. 2010 March; 107(9): 152-162 21. Adaptions with the help of Cambridge & Perborough PCT policy, Middlesborough PCT policy, Wirral PCT policy
Table 1: Classification of pain level 1 Pain Level Slight Moderate Intense Severe Sporadic pain. Pain when climbing/descending stairs. Allows daily activities to be carried out (those requiring great physical activity may be limited). Medication, aspirin, paracetamol or NSAIDs 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 with no/few side effects. Pain of almost continuous nature. Pain when walking short distances on level surfaces or standing for less than half an hour. Daily activities significantly limited. Continuous use of NSAIDs for treatment to take effect. Requires the sporadic use of support systems walking stick, crutches). Continuous pain. Pain when resting. Daily activities 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). Table two: Functional Limitations 2 Functional limitations Functional capacity adequate to conduct normal activities and self care Minor Walking capacity of more than one hour No aids needed Functional capacity adequate to perform only a few or none of the normal activities and self care Moderate Walking capacity of about one half hour Aids such as a cane are needed Largely or wholly incapacitated Severe Walking capacity of less than half hour or unable to walk or bedridden Aids such as a cane, a walker or a wheelchair are required 1 Lequesne M. Indices of severity and disease activity for osteoarthritis. Seminars in Arthritis Research, 1991;20:48-54 2 Hochberg et al. The American College of Rheumatology 1991 revised criteria for the classification of global functional status in rheumatoid arthritis. Arthritis Rheum, 1992;35:498-502