Care map information Resources for patients, carers and clinicians. Referral indicators Red flags -infection in previous Total Hip Replacement (THR) -pathological fracture Hip arthritis Patient with previous THR - loosening/wear, pain Other hip pain History, examination, investigations History, examination, investigations History, examination, investigations Non surgical management options Non-surgical referral options Information to include in referral REFERRAL Peninsula Health Orthopaedic outpatients clinic REFERRAL St Vincents Elective Surgery - ESAS (Public) REFERRAL Private orthopaedic surgeon Page 1 of 7
1 Care map information This pathway is about: primary care management of osteoarthritis (OA) in hip and knee in adults indications for referral to secondary care providers pathways for referral into hip and knee surgery This pathway is not about: infective or inflammatory arthropathies secondary arthropathies specific management of arthritis affecting other parts of the body Definition: OA refers to a clinical syndrome of joint pain accompanied by varying degrees of functional limitation and reduced quality of life [1] OA is characterised pathologically by localised loss of cartilage, remodelling of adjacent bone, and associated inflammation [1] Aetiology [1]: a variety of traumas may trigger the need for a joint to repair itself OA includes a slow but efficient repair process that often compensates for the initial trauma, resulting in a structurally altered but symptom-free joint in some people, because of either overwhelming trauma or compromised repair, the process cannot compensate, resulting in eventual presentation with symptomatic OA Incidence and prevalence [1]: the exact incidence and prevalence of OA is difficult to determine because the clinical syndrome of OA (joint pain and stiffness) does not always correspond with the structural changes of OA (usually defined as abnormal changes in the appearance of joints on radiographs) OA is the most common form of arthritis, with more than 50% of people >65 years of age demonstrating radiological evidence of OA [2] On modelled estimates (07-08), Frankston-Mornington has a slightly higher prevalence of OA (8.6%) than the Australian average (7.6%) but is on par with the Victorian average (8.7%) musculoskeletal conditions, particularly osteoarthritis, accounted for 17% of visits to Australian GPs in 2003-4 [2] Arthritis Victoria data indicates that 1.5 million Victorians currently live with a chronic musculoskeletal condition and is projected to increase by 43% over the next two decades, primarily due to increased numbers of people with OA Risk factors: genetic factors heritability is estimated at 40 60% for hip and knee OA [1] constitutional factors (for example, ageing, female sex, obesity, high bone density) [1] more local, largely biomechanical risk factors (for example, joint injury, occupational/recreational usage, reduced muscle strength, joint laxity, joint malalignment) [1] other diseases, eg: inflammatory arthritis: rheumatoid arthritis infection crystal arthritis avascular necrosis Paget's disease Prognosis [1]: OA is not necessarily a progressive disease that inevitably leads to increasing pain and disability, although this is a common misconception amongst the public and many healthcare professionals OA is an attempted repair process and in the majority of cases this process limits damage and symptoms knee OA is very variable in its outcome, however, improvement in pain and disability over time is common hip OA: Page 2 of 7
has a poorer outcome than knee a significant proportion of patients require hip replacement within 5 years of symptom onset References: 1. National Clinical Guideline Centre (NCGC). Osteoarthritis: care and management in adults. Clinical guideline 177. London: NCGC at the Royal College of Physicians; 2014. 2. National Health and Medical Research Council (NHMRC), The Royal Australian College of General Practitioners (RACGP). Guideline for the non-surgical management of hip and knee osteoarthritis. South Melbourne, VIC: NHMRC; 2009. 3. Australian Bureau of Statistics 4. Arthritis and Osteoporosis Australia website 2 Resources for patients, carers and clinicians. Arthritis Victoria is the recommended source of information for patients and carers Clinical guidelines RACGP is the best source of clinical guideline information in Australia 2009 RACGP Guidelines for non-surgical management of Osteoarthritis of the hip and knee Summary article of 2009 RACGP guidelines for GPs RACGP Article on osteoarthritis pain and therapy Peninsula Health referral guidelines 3 Referral indicators Consider referral for joint surgery for people with arthritis of hip who experience joint symptoms (pain, stiffness, and reduced function): that have a substantial impact on their quality of life: all adults with painful irritable and stiff hip interfering with sleep, mobility, activities of daily living, work or leisure that are refractory for up to 3 months of non-surgical treatment before there is prolonged and established functional limitation and severe pain regardless of the radiographic grade of disease 4 Red flags -infection in previous Total Hip Replacement (THR) -pathological fracture If suspected, these conditions require urgent acute care. If infection is suspected, make urgent referral: DO NOT START ANTIBIOTICS 5 Patient with previous THR - loosening/wear, pain If patient's previous THR was performed at a hospital outside of this catchment, consider if it is practical to refer to their previous hospital for continuity of management. 6 Hip arthritis Page 3 of 7
Hip arthritis: osteoarthritis inflammatory arthritis post-traumatic arthritis avascular necrosis 7 Other hip pain If patient is experiencing hip pain but does not have significant radiological changes, consider other causes of hip pain; back pain radiating to the hip (NB spinal or back conditions not treated at PH orthopaedic surgical outpatients) referred pain tendinopathy bursitis labral tear or impingement (rare and can only be seen on an MRI) 8 History, examination, investigations Standard history and examination - key points: walking distance rest pain and disturbance of sleep locking and/or instability ability to put on shoes treatment including NSAIDs and analgesics general medical conditions and medication history of recurrent infections and consideration of prostate malignancy Examination always ensure that you examine the hip to differentiate between hip and back pathology Investigations: X-ray: AP pelvis AP affected hip showing 2/3 femur lateral affected hip 9 History, examination, investigations Standard history and examination - key points: new pain affected gait pattern Investigations: X- ray (weight bearing): lateral hip AP pelvis Page 4 of 7
Additional considerations: Pain in previous arthroplasty should have an X-ray performed and referred immediately for triage 10 History, examination, investigations Standard history and examination - key points: walking distance rest pain and disturbance of sleep locking and/or instability ability to put on shoes treatment including NSAIDs and analgesics general medical conditions and medication history of recurrent infections and consideration of prostate malignancy Investigations: X-ray: AP pelvis AP affected hip showing 2/3 femur lateral affected hip 11 Non surgical management options Ensure conservative management options have been considered or implemented: anti-inflammatories analgesics physiotherapy weight management activity modification including the use of a walking stick. home modification. See osteoarthritis management for more detail. 12 Non-surgical referral options Consider other interventions to address potential cause of pain that may not benefit from surgery. If the diagnosis is unclear or there is difficulty differentiating between back pain referred to hip and hip disease consider referral to: sports physician rheumatologist physiotherapist Go to osteoarthritis management for referral options. 13 Information to include in referral Recent radiological investigation results are essential. All referrals must contain: Patient details including DOB, address and current home and mobile phone numbers GP details including name, address and contact details Page 5 of 7
History and duration of complaint Symptoms and severity of complaint Appraisal of general health of patient, particularly cardiac and diabetic disease and a current list of medications, particularly anti-coagulants Accurate Triage (particularly for public orthopaedic services) is assisted by; Details of conservative treatment to date How condition affects Activities of Daily Living Social history eg: employment or carer status- how the complaint affects this directly affects triage Stipulation of new patient/complaint or review patient for same complaint (review patients for same complaint seen earlier) 14 REFERRAL Peninsula Health Orthopaedic outpatients clinic Peninsula Health (Public) Referral are triaged by an orthopaedic surgeon. Radiological investigation results are essential. Detailed information on the Peninsula Health orthopaedic specialist clinic and referral requirements can be found here. Comprehensive referrals as per the guidelines assist accurate prioritisation of patient needs. Referrals to the Orthopaedic unit should be addressed to the Head of Unit, Mr Peter McCombe, dated and signed, and include relevant investigations: fax (preferred); 9784 2666 post; Outpatient service - Orthopaedic Peninsula Health PO Box 52, Frankston, 3199 phone (for discussion of urgent cases only); 9784 7777 and ask to speak to Orthopaedic Registrar on call. Referrals for Hip orthopaedic assessment and surgery at Peninsula Health; are triaged by an orthopaedic surgeon are seen by the musculoskeletal physiotherapist in the Osteoarthritis Hip and Knee Service (OAHKS) who will optimise nonoperative treatment and prioritise patients for review by a surgeon in the orthopaedic clinic severe problems (social circumstances taken into account as well as physical symptoms and signs) will be triaged as urgent and fast tracked may be put on the orthopaedic surgical waiting list after review by the surgeon: current waiting time for surgery in these circumstances is 6-9 months (varies with demand) When nearing surgery on the waiting list, patients will be asked to obtain another xray less than 3/12 prior to surgery. 15 REFERRAL St Vincents Elective Surgery - ESAS (Public) St Vincents Elective Surgery - ESAS (Public) ESAS accepts referrals statewide. Surgical follow up and management of complications needs to be attended at St Vincents May have a shorter waiting time, but weigh up against implications of travel for both patients and relatives. Physiotherapy / rehabilitation follow-up can be done locally. For more information and referral pathways/requirements, click here For more information on referral options if patient is assessed as not suitable for orthopaedic surgery, go to OA management page 16 REFERRAL Private orthopaedic surgeon Page 6 of 7
Private orthopaedic surgery options Refer to private orthopaedic surgeon only if patient has private health insurance as, in this region, private surgeons are not able to put patients on the public waiting list from their private rooms. Options for private orthopaedic consultation and surgery on Frankston Mornington Peninsula: list provided by Peninsula Health orthopaedic unit December 2014. Orthopaedic surgeons listed on the National Health Services Directory Frankston Mornington Page 7 of 7
Orthopaedics Hip surgery referral Surgery / Orthopaedics Provenance certificate Contents Overview Editorial methodology Contributors Disclaimers Overview This document describes the provenance of the Peninsula Pathways, Hip surgery referral. This pathway was last reviewed in May 2016 by: Dr Nigel Broughton, Orthopaedic Surgeon, Peninsula Health Mark Dennis, Senior Physiotherapist Osteoarthritis Hip and Knee Program, Peninsula Health The Peninsula Pathways Program aims to improve the continuity of patient care between primary, community and hospital care settings in the Frankston-Mornington Peninsula region. Work groups comprising of experienced health professionals (GPs, specialists, nurses, allied health professionals) were established to review and localise pathways. The objective of this pathway is to improve referral processes for knee surgery in the Frankston Mornington catchment. Published: 16/01/2015 Valid until: 16/01/2017 To cite this pathway, use the following format: Map of Medicine (MoM). Hip surgery referral. Frankston-Mornington Peninsula Medicare Local View. Melbourne: Map of Medicine; 2015. Editorial methodology This pathway is currently the first version localised to Frankston Mornington Peninsula. This care map has been developed according to the Map of Medicine editorial methodology. The content of this care map was based on Peninsula Health orthopaedics guidelines and further developed with practice-based knowledge provided by local practitioners with front-line clinical experience (see contributors section of this document).
Orthopaedics Hip surgery referral Surgery / Orthopaedics Contributors The following were clinical contributors to the Osteoarthritis Hip and Knee pathway: Dr Nigel Broughton Orthopaedic Surgeon, Peninsula Health Dr Geoff Campbell General Practitioner, Langpark Medical Centre Dr Michael Cross General Practitioner, Mornington Medical Group Mark Dennis Senior Physiotherapist, Osteoarthritis Hip and Knee Program (OAHKS), Peninsula Health Nicola Lindsay Senior Physiotherapist, Osteoarthritis Hip and Knee Program (OAHKS), Peninsula Health Editor/facilitator support: Dianne Berryman Integrated Chronic Disease Management Coordinator, Frankston-Mornington Peninsula PCP Nick Jones Service Integration Manager, Frankston Mornington Peninsula Medicare Local The following were contributors as part of the Osteoarthritis Hip and Knee pathway wider consultation group: Dr Jo Newton GP Liaison, Peninsula Health Dr Emma Donovan General Practitioner, Langpark Medical Centre Dr Glenn Mathieson General Practitioner, Langpark Medical Centre Conflicts of interest: None Disclaimers It is not the function of the Pathways Program, Frankston-Mornington Peninsula Medicare Local to substitute for the role of the clinician, but to support the clinician in enabling access to know-how and knowledge. Users of the Map of Medicine are therefore urged to use their own professional
Orthopaedics Hip surgery referral Surgery / Orthopaedics judgement to ensure that the patient receives the best possible care. Whilst reasonable efforts have been made to ensure the accuracy of the information on this online clinical knowledge resource, we cannot guarantee its correctness and completeness. The information on the Map of Medicine is subject to change and we cannot guarantee that it is up-to-date