Hip Replacement Surgery

Transcription

1 Hip Replacement Surgery

2 VERSION CONTROL Version: 2.0 Ratified by: Governing Body Date ratified: 03 April 2013 Name of originator/author: Name of responsible committee: Clinical Quality and Governance Date issued: 03 April 2013 Review date: April 2016 VERSION HISTORY Date Version Comment / Update April Version 1 for PCT, April /04/ Version 2.0 amended for CCG and approved on 03 April 2013 Page 2 of 21

3 Contents 1. Policy Statement Key points Scope of the policy Referral criteria for routine referral to orthopaedic services Thresholds for hip replacement surgery Appendix 1 Definitions Appendix Appendix Appendix Classification of Pain Levels and Functional Limitations Table Classification of Pain Levels and Functional Limitations Table Page 3 of 21

4 1. Policy Statement 1.1. Referral to an acute provider for consideration of hip replacement surgery should only be made if specific criteria are met, as detailed below under Referral criteria for routine referral to orthopaedic services 1.2. Hip replacement surgery should only be undertaken by an acute provider if specific criteria are met, as detailed below under Thresholds for hip replacement surgery 2. Key points A review of systematic reviews and health technology assessments looking at the evidence base for clinical measurement tools to assess referral threshold for hip replacement was recently undertaken by the Aggressive Research Intelligence Facility (ARIF) at the University of Birmingham. 1 This found no systematic reviews or health technology assessments that had directly investigated clinical measurement tools to help treatment decisions regarding hip replacement. However, it identified two clinical guideline documents that gave recommendations on referral of patients for hip replacement and one systematic review that examined the effectiveness of clinical pathways in the treatment of patients with hip pathology. 1 Of the guidelines, one was issued by the National Institute for Health and Clinical Excellence (NICE). 2 The NICE guidelines suggested that referral for joint replacement surgery should be considered for people with osteoarthritis who experience joint symptoms (pain, stiffness, reduced function) that have a substantial impact on their quality of life and are refractory to non-surgical treatment. Referral should be made before there is prolonged and established functional limitation and severe pain. The conclusion of the review by ARIF was No systematic reviews or health technology assessments were identified that had investigated clinical measurement tools to help treatment decisions regarding hip replacement. Two national guidelines that make recommendations on referral for hip replacement surgery were identified, however, neither is based on patient assessments using clinical measurement tools. A number of primary care trusts in England have existing published policies on thresholds for referral of patients with hip pain due to osteoarthritis from primary care to secondary care and/or thresholds for elective primary hip replacement surgery. 3,4,5 1 Aggressive Research Intelligence Facility (ARIF) (2010) Clinical measurement tools and referrals for hip replacement. [Online] Available from: Tools-and-Referrals-for-Hip-Replacement-April-2010.pdf [Accessed 20 September 2010] 2 The National Collaborating Centre for Chronic Conditions (Royal College of Physicians) / National Institute for Health and Clinical Excellence (NICE) (2008) Osteoarthritis - National clinical guideline for care and management in adults. [Available online from: Accessed 20 September 2010] 3 Cambridgeshire and Peterborough Public Health Network (2007) Surgical threshold policy - Primary Hip Replacement Surgery: Non-acute. [Online] Available from: _Non-Acute_-_Surgical_Threshold_Policy.sflb.ashx [Accessed 20 September 2010] Page 4 of 21

5 This policy is largely based on policies previously published by Cambridgeshire and Peterborough Public Health Network and by Bedfordshire and Hertfordshire Priorities Forum. 3,4 3. Scope of the policy The most common indication for elective primary total hip replacement (THR) is degenerative arthritis (osteoarthritis) of the joint. Other indications include rheumatoid arthritis, injury, bone tumour and necrosis of the hip bone. 3,4 This policy applies only to elective primary hip replacement for osteoarthritis. The relevant 3-character OPCS codes 6 (where used for elective primary hip replacement for osteoarthritis) include: W37 Total prosthetic replacement of hip joint using cement W38 Total prosthetic replacement of hip joint not using cement W39 Other total prosthetic replacement of hip joint W93, W94, W95 - Hybrid prosthetic replacement of hip joint The CCG will agree to fund referrals and surgery where the patient meets the following criteria. Although prior approval will not be necessary under the policy the following proforma may be helpful: See Appendix 3 for a copy of a proforma that may be used by primary care when making a referral See Appendix 4 for a copy of a proforma that may be completed in secondary care for audit purposes 4 Bedfordshire and Hertfordshire Priorities Forum (2009) Statement Number: 32. Referral criteria for patients from primary care presenting with hip pain due to osteoarthritis, and clinical thresholds for elective primary hip replacement surgery. [Online] Available from: andsurgerythresholdsupdatednov09.pdf [Accessed 20 September 2010] 5 NHS Suffolk (2009) Low Priority Threshold Procedure T18 - Hip and knee replacement surgery. [Online] Available from: [Accessed 20 September 2010] 6 The Information Centre for health and social care (NHS) HES online - Main procedures and interventions: 3 character, [Online] Available from: ccessing\datatables\operations\3%20character\mainop3_0809.pdf&short_name=mainop3_0809.pdf&u_i d=8574 [Accessed 20 September 2010] Page 5 of 21

6 4. Referral criteria for routine referral to orthopaedic services Candidates for elective THR should have: Moderate* to severe* persistent pain not adequately relieved by an extended course of nonsurgical* management (including weight management where appropriate see below) AND clinically significant functional limitation resulting in diminished quality of life AND radiographic evidence of joint damage. Smoking cessation and weight management should be considered as an integral part of appropriate clinical management prior to consideration of any elective surgery. In addition to this general consideration, weight management is a specific part of the non-surgical management of osteoarthritis affecting the hip and knee joints. Evidence about the relationship between obesity and the outcomes of hip replacement surgery appears to be mixed. This is discussed in Appendix 2. However, in general, evidence seems to suggest that THR generally leads to beneficial outcomes in both obese and non-obese patients; but the magnitude of improvement is likely to be greater, and the incidence of complications lower, in patients with lower body mass index (BMI). All patients who smoke should be referred to appropriate smoking cessation services. All patients who are overweight (BMI ) or obese (BMI > 30) should be encouraged and supported to reduce their BMI, including referral to specialist weight management services where indicated. 5. Thresholds for hip replacement surgery Evidence suggests that the following patients would benefit from hip joint replacement surgery: 3,4,7,8 1. When the patient complains of severe* joint pain AND EITHER has severe* functional limitation irrespective of whether conservative management has been trialled, OR has minor* to moderate* functional limitation, despite the correct* use of non-surgical treatments such as adequate doses of NSAID analgesia, weight control treatments and physical therapies. 2. Where the patient complains of mild* to moderate* joint pain 7 Quintana JM, 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: Quintana JM, Escobar A, Arostegui I, Bilbao A, Azkarate J, Goenaga I and Arenaza J. Health related quality of life and appropriateness of knee or hip joint replacement. Archives of Internal Medicine, 2006; 166: [Available in full text from: Accessed 20 September 2010] Page 6 of 21

7 AND has severe* functional limitation, despite the correct* use of non-surgical treatments such as adequate doses of NSAID analgesia, weight control treatments and physical therapies, AND is assessed to be at low surgical risk. * See Appendix 1 for definitions. Patients who are morbidly obese (BMI > 40) should not normally be listed for hip joint replacement surgery unless all reasonable attempts have been made to reduce weight and there are compelling circumstances such as: Patients whose pain is so severe and/or mobility so compromised that they are in immediate danger of losing their independence and that joint replacement would relieve this threat, or patients in whom the destruction of their joint is of such severity that delaying surgical correction would increase the technical difficulty of the procedure. Page 7 of 21

8 6. Appendix 1 Definitions (Taken from: Bedfordshire and Hertfordshire Priorities Forum (2009) Statement Number: 32. Referral criteria for patients from primary care presenting with hip pain due to osteoarthritis, and clinical thresholds for elective primary hip replacement surgery. [Online] Available from: andsurgerythresholdsupdatednov09.pdf [Accessed 20 September 2010]) Variable Definition Pain level - Mild Pain interferes minimally on an intermittent basis with usual daily activities Not related to rest or sleep Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol - Moderate Pain occurs daily with movement and interferes with usual daily activities Vigorous activities cannot be performed Not related to rest or sleep Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol - Severe Pain is constant and interferes with most activities of daily living Previous non-surgical treatments Pain at rest or interferes with sleep Pain not controlled, even by narcotic analgesics - Correctly Done NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses during 6 months with no pain relief; weight control treatment if overweight, physical therapies done - Incorrectly Done NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses or less than 6 months with no pain relief; or no weight control treatment if overweight, or no physical therapies done Functional Limitations - Minor Functional capacity adequate to conduct normal activities and self care Walking capacity of more than one hour No aids needed - Moderate Functional capacity adequate to perform only a few or none of the normal activities and self care Page 8 of 21

9 Walking capacity of about one half hour Aids such as a cane are needed - Severe Largely or wholly incapacitated 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 Page 9 of 21

10 7. Appendix 2 The evidence about the relationship between obesity and the outcomes of hip replacement surgery appears to be mixed. For example: The NICE guideline on osteoarthritis, published in 2008, suggested that patient-specific factors (including age, gender, smoking, obesity and comorbidities) should not be barriers to referral for joint replacement therapy. 2 A review published in the Annals of the Royal College of Surgeons of England in reported that the authors identified nine papers that examined the impact of BMI on outcome following total hip replacement surgery. Some papers suggested that obese patients were more likely to develop a postoperative complication (i.e. short-term) and had longer operations and more blood loss; however, the rates of other complications were similar (and one study was reported to show that obese patients had a lower incidence of minor and major complications. In the medium term, one study failed to demonstrate a difference in quality of life at 1 and 3 years postoperatively between obese and non-obese patients; while another study showed that the Harris Hip Score increased dramatically in all patients, although obesity did predict a lower score at 6 and 18 months. (It was reported, however, that both studies concluded that patients should not be denied the benefits of total hip replacement on the basis of obesity alone.) This review reported that there is a paucity of evidence in the literature regarding the long-term affects of obesity on the survival of total hip replacements. It found only one paper which reported results with more than 10-year follow-up, and this reported no difference in outcome between normal, obese (BMI kg/m 2 ) and morbidly obese (BMI > 40 kg/m 2 ) patients, though the overall survival of the hip was poor at 18 years in both groups because of a high failure rate in the uncemented acetabular component. This review concluded that we could find no convincing evidence in the literature to support the policy of denying anyone a hip replacement on the grounds of obesity. 9 A recently-published study compared 55 consecutive total hip replacements performed on 53 morbidly obese patients with osteoarthritis with a matched group of 55 total hip replacements in 53 non-obese patients. 10 The groups were matched for age, gender, prosthesis type, laterality and preoperative Harris Hip Score. They were followed prospectively for five years and the outcomes were assessed using the Harris Hip Score, the Short-form 36 score and radiological findings. Survival at five years (using revision surgery as an endpoint) was 90.9% (95% confidence interval 82.9 to 98.9) for the morbidly obese and 100% for the non-obese patients. The Harris Hip and the Short-form 36 scores were significantly better in the nonobese group (p < 0.001). The morbidly obese patients had a higher rate of complications (22% vs 5%, p = 0.012), which included dislocation and both superficial and deep infection. The abstract of this paper concluded that in light of these inferior results, morbidly obese patients should be advised to lose weight before undergoing a total hip replacement, and counselled regarding the complications. Despite these poorer results, however, the patients have improved function and quality of life Davis W, Porteous M. (2007) Joint replacement in the overweight patient: a logical approach or new form of rationing? Annals of the Royal College of Surgeons of England, 89(3): [Available online in full text from: Accessed 20 September 2010] 10 Abstract of: Chee YH, Teoh KH, Sabnis BM, Ballantyne JA, Brenkel IJ. (2010) Total hip replacement in morbidly obese patients with osteoarthritis: results of a prospectively matched study. Journal of Bone & Joint Surgery - British Volume, 92(8): [ Abstract available from: Accessed 20 September 2010] Page 10 of 21

11 Another recently-published study found that higher BMI was one of the factors associated with both moderate-severe pain and use of pain medications at 2 years and 5 tears after primary THR. 11 The abstract of another recent paper reported that, although morbidly obese (MO) patients experienced significantly longer operation times (66 minutes vs. 58 minutes) and longer wounds (14.2 cm vs cm) compared to normal THR patients, intra-operative anaesthetic time and length of hospital stay were not significantly different between the two groups. 12 Improvements in patient outcomes following THR were not significantly different between the MO and normal patients at one year follow-up, although improvements in sagittal range of motion and external rotation were significantly less for MO patients. Intraoperative complication rates were 0% for the MO and 3.5% for the normal patients, while postoperative complication rates were 3.5% for the MO and 0% for the normal patients. As hospital length of stay was not longer for MO patients, it is suggested that they do not represent a greater burden on healthcare resources during THR. 12 Another paper reported on the outcome of 2026 consecutive primary cementless THRs performed for osteoarthritis, with mean follow-up of 6.3 years (0 to 11.71). 13 The patients were divided into two groups: non-obese (BMI < 30 kg/m 2 ) and obese (BMI 30 kg/m 2 ). The obese patient undergoing surgery was found to be significantly younger (p < 0.001). There was no difference in the mid-term survival between the non-obese and obese groups. The clinical and radiological outcome was determined in a case-matched study performed on 134 obese individuals closely matched with 134 non-obese controls. The non-obese group was found to have a significantly higher post-operative Harris hip score (p < 0.001) and an increased range of movement, but overall satisfaction with surgery was comparable with that of the obese patients. Radiological analysis showed no significant differences. It is suggested that these results demonstrate that the survival of cementless THR is not adversely affected by obesity. Obese patients can therefore be counselled that despite a lower clinical score, they should expect to be satisfied with the result of their THR with a mid-term survival rate equivalent to that of non-obese patients. 13 Another paper reported on follow-up of a multi-centre cohort, using data on 20,553 primary THRs (18,968 patients) for a follow-up period of up to 15 years. 14 Patients were classified into three BMI groups (normal weight <25 kg/m 2, overweight 25 to <30 kg/m 2, and obese 30 kg/m 2 ), and pain status and functional outcome were compared accordingly. The paper found 11 Singh JA, Lewallen D. (2010) Predictors of pain and use of pain medications following primary Total Hip Arthroplasty (THA): 5,707 THAs at 2-years and 3,289 THAs at 5-years. BMC Musculoskeletal Disorders, 11:90. [Available online in full text from: [ Accessed 20 September 2010] 12 Abstract of: Bennett D, Gibson D, O'Brien S, Beverland DE. (2010) Hip arthroplasty in morbidly obese patients - intra-operative and short term outcomes. Hip International, 20(1): [ Abstract available from: CFA72DD2C1CA&t=hip Accessed 20 September 2010] 13 Abstract of: Jackson MP, Sexton SA, Yeung E, Walter WL, Walter, WK, Zicat BA. (2009) The effect of obesity on the mid-term survival and clinical outcome of cementless total hip replacement. Journal of Bone and Joint Surgery - British Volume, 91(10): [Abstract available from: Accessed 20 September 2010] 14 Abstract of: Busato A, Roder C, Herren S, Eggli S. (2008) Influence of high BMI on functional outcome after total hip arthroplasty. Obesity Surgery, 18(5): [Abstract available from: Accessed 21 September 2010] Page 11 of 21

12 that high preoperative BMI is associated to an almost perfect dose effect relationship with decreased ambulation during a follow-up period of 15 years, but pain relief is equally efficient for all BMI groups. It suggested that overweight and obesity are modifiable risk factors that may warrant physicians giving recommendations to patients before or after [THR], to improve postoperative functional outcome quality. 14 Another study looking at a hospital-based cohort of patients who underwent THR (2,495 hips) found that obesity was associated with a substantially higher risk for deep infection in women, led to more dislocations (increase greater in women), and resulted in more revisions for septic loosening. 15 This study also found that obese women, but not obese men, reported moderately lower functional outcomes and less satisfaction, the latter partly due to a higher incidence of complications among these patients. 15 In summary, the evidence seems to suggest that THR generally leads to beneficial outcomes in both obese and non-obese patients; but the magnitude of improvement is likely to be greater be greater, and the incidence of complications lower, in patients with lower BMIs. 15 Lübbeke A, Stern R, Garavaglia G, Zurcher L, Hoffmeyer P. (2007) Differences in outcomes of obese women and men undergoing primary total hip arthroplasty. Arthritis and Rheumatism, 2007, 57(2): [Available online in full text from: Accessed 21 September 2010] Page 12 of 21

13 8. Appendix 3 Primary Hip Replacement Surgery Referral Proforma for GPs Patient Details Name: NHS Number: Date of Birth: Address: Clinician Details Name of Referring Clinician: Practice: Practice Telephone Number: Date: Please enter referral letter text here (optional). Please expand or shrink box as required. Page 13 of 21

14 Please state clearly if the referral is outside of policy and a specialist opinion is required, giving relevant clinical information. Referral criteria - patients should meet all the following criteria and referred appropriately: Referral should be made when other pre-existing medical conditions have been optimised AND conservative measures have been exhausted and failed. Please state the patients Body Mass Index at the time of going onto the waiting list for surgery:... Is the patient a smoker? Yes/No If Yes, has patient been referred to smoking cessation? Yes/No NHS Number:. Please refer to the classification of pain levels and functional limitations in the table overleaf. The initial non-surgical management of hip pain due to osteoarthritis has been provided, ie a package of care that may include weight reduction, activity modification, adequate doses of non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics, introducing walking aids, and other forms of physical therapies. Patient has moderate to severe persistent pain not adequately relieved by an extended course of non-surgical management (including weight management) tick boxes as appropriate AND AND Clinically significant (moderate to severe) functional limitation resulting in diminished quality of life. Radiographic evidence of joint damage. Page 14 of 21

15 I have reviewed this referral against NHS South Warwickshire s Commissioning Policy: Referral and surgical threshold criteria for elective primary hip replacement surgery Page 15 of 21

16 9. Appendix 4 Primary Hip Replacement Surgery Proforma for Consultants/Specialists Patient Details Name: NHS Number: Date of Birth: Clinician Details Name of Referring Clinician: Hospital Trust: Please state the patients Body Mass Index at the time of going onto the waiting list for surgery... Please refer to the classification of pain levels and functional limitations in the table overleaf. tick boxes as appropriate A The patient has severe joint pain: AND has severe functional limitation irrespective of whether conservative management has been trialled; Page 16 of 21

17 OR has minor to moderate functional limitation, despite the use of non-surgical treatments such as adequate doses of NSAID analgesia, weight control treatments and physical therapies. OR B The patient has mild to moderate joint pain: AND has severe functional limitation, despite the use of non-surgical treatments such as adequate doses of NSAID analgesia, weight control treatments and physical therapies. AND is assessed to be at low surgical risk. Page 17 of 21

18 10. Classification of Pain Levels and Functional Limitations Table Variable Pain Level Mild Definition Pain interferes minimally on an intermittent basis with usual daily activities. Not related to rest or sleep. Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol. Pain occurs daily with movement and interferes with usual daily activities. Moderate Vigorous activities cannot be performed. Not related to rest or sleep. Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol. Pain is constant and interferes with most activities of daily living. Severe Pain at rest or interferes with sleep. Previous non-surgical treatments Correctly Done Pain not controlled, even by narcotic analgesics. NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses during 6 months with no pain relief; weight control treatment if overweight, physical therapies done. Incorrectly Done NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses or less than 6 months with no pain relief; or no weight control treatment if overweight or no physical therapies done. Functional Limitations Functional capacity adequate to conduct normal activities and self care. Minor Walking capacity of more than one hour. No aids needed. Moderate Functional capacity adequate to perform only a few or none of the normal activities and self care. Walking capacity of about one half hour. Aids such as a cane are needed. Page 18 of 21

19 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. Page 19 of 21

20 11. Classification of Pain Levels and Functional Limitations Table Variable Pain Level Mild Definition Pain interferes minimally on an intermittent basis with usual daily activities. Not related to rest or sleep. Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol. Pain occurs daily with movement and interferes with usual daily activities. Moderate Vigorous activities cannot be performed. Not related to rest or sleep. Pain controlled by one or more of the following: NSAIDs with no or tolerable side effects, aspirin at regular doses, paracetamol. Pain is constant and interferes with most activities of daily living. Severe Pain at rest or interferes with sleep. Previous non-surgical treatments Correctly Done Pain not controlled, even by narcotic analgesics. NSAIDs, paracetamol, aspirin or narcotic analgesics at regular doses during 6 months with no pain relief; weight control treatment if overweight, physical therapies done. Incorrectly Done NSAIDs, paracetamol, aspirin or narcotic analgesics at inadequate doses or less than 6 months with no pain relief; or no weight control treatment if overweight or no physical therapies done. Functional Limitations Functional capacity adequate to conduct normal activities and self care. Minor Walking capacity of more than one hour. No aids needed. Moderate Functional capacity adequate to perform only a few or none of the normal activities and self care. Walking capacity of about one half hour. Aids such as a cane are needed. Severe Largely or wholly incapacitated. Walking capacity of less than half hour or unable to walk or bedridden. Page 20 of 21

21 Aids such as a cane, a walker or a wheelchair are required. Page 21 of 21