Osteoarthritic Hip Pain Commissioned Pathway - Western locality

Scope

This is the commissioned pathway for hip pain due to osteoarthritis

450 patients per 100 000 population present to primary care annually with hip pain

25% resolve in 3 months – 35% at 12 months

Pain felt around and attributed to the hip can also be due to spinal or abdominal disorders which should be excluded.

Hip pathology may cause pain felt only at the knee.

Degenerative hip disease is the most common diagnosis in the adult and is the long-term consequence of predisposing conditions.

Osteoarthritis (OA) may not be progressive and most patients will not need surgery, with their symptoms adequately controlled by nonsurgical measures. Symptoms progress in 15% of patients within 3 years and 28% within 6 years.

Unless red flags are present all patients referred for consideration of arthroplasty due to osteoarthritis will be assessed by a community assesment service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Please note pre-referral criteria are applicable in this referral and referrals may be returned if this information is not contained within the referral

Please note primary care is encouraged to follow In Shape for Surgery best practice which can be seen here.

Out of Scope

Hip pain for reasons other than osteoarthritis: see Hip Pain and Management in Adults

  • DRSS will review the referral letter and direct to Orthopaedics if:
    • Under 16 years of age
    • Arthroscopy recommended by an orthopaedic specialist in those under 18 years of age
    • Recent surgery same joint less than six month ago
    • Metal work in situ in the area
    • Previous arthroplasty same joint/joint replacement
    • Inflammatory Arthritis
    • Suspected serious pathology (see Red Flags)
    • Leaking wound/possible infections
    • The following hip condition:
      • Protrusio acetabula

Assessment

History

Please include detail such as:

  • Pain
    • In the groin, medial thigh or greater trochanter radiating to thigh or knee at rest and/or after activity
    • isolated knee pain
  • Impact on occupation, daily activity or sports (e.g. decrease in walking distance, difficulty in negotiating stairs or performing pedicure)
  • Duration and onset
  • Aggravating and relieving factors
  • Perthes
  • Details of previous surgery

Red Flags

Red Flags which will bypass the Community Assesment Service (should be referred urgently to secondary care)

  • Fracture or trauma
  • Suspicion of tumour or evidence of any destructive lesion on radiograph
  • Unexplained, increasing or sudden onset severe pain in a previously replaced joint
  • Any features suspicious of infection, including:
    • Cellulitis over the joint
    • Large effusion and erythema
    • Inflamed scar/wound over a previously replaced joint
  • Inability to walk or weight bear
  • Evidence of new inflammatory arthropathy
  • Avascular necrosis/osteonecrosis
  • The following hip condition:
    • Protrusio acetabula

Investigations

**ADDENDUM 24/5/21 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **


  • A plain A-P X-ray of the pelvis should ideally be requested to confirm the diagnosis after history and examination if OA is suspected.

The clinical indications for this are:

1) to rule OA in or out as a differential for the patient's symptoms

2) to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g., avascular necrosis (an indication for expedited referral)

3) deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up-to-date X-ray is extremely useful for remote/virtual consultations.

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient’s symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.


  • No further imaging (e.g., MRI or bone scan) is appropriate before referral.

Management

Mild Symptoms

  • see MyHealth Devon Hip Pain (Osteoarthritis)
  • Offer verbal and written information about condition
  • Offer information to support weight loss if people are overweight or obese (BMI greater than 30) as a core treatment
  • Advise on local muscle strengthening and general aerobic exercise as a core treatment
  • Use of shared decision making tools
  • Suggest OTC oral simple analgesia and anti-inflammatory medication
  • Assess need for aids and devices (refer to occupational therapy or physiotherapy) including instruction in using a walking aid
  • Prescribe supervised and evidence based physical therapies - refer to Local Physiotherapy Service

Moderate Symptoms:

Unless red flags are present all patients referred for consideration of arthroplasty due to osteoarthritis will be assessed by a community assessment service which provide a holistic assessment of their symptoms and disabilities before being helped to make a decision on the possible treatment options. This assessment will include Oxford hip scoring and patient decision making aids. Treatment options will include lifestyle modifications, physiotherapy, improved general health and well being or surgery.

Surgery

  • Primary Hip Replacement
  • Hip Resurfacing is commissioned in line with NICE TA 304 (Total Hip Replacement and resurfacing arthroplasty for end-stage arthritis of the hip). Other forms of arthroscopic or open hip surgery are low priority procedures and will only be funded through exceptional cases panel approval

Referral

Referral Criteria

Referral to specialist secondary care:

All referrals should include:

  • History and duration
  • Instability symptoms or history of overuse
  • Relevant examination findings
  • Relevant investigations

All referrals must include:

  1. Details of persistent pain or disability that has not responded to up to 12 weeks of evidence based nonsurgical treatments. Please include details (including dates) of conservative treatment (e.g. analgesia, steroid joint injection)
  2. A recent course of physiotherapy will be expected unless this is not clinically appropriate (within the twelve months prior to referral). This clinical decision needs to be stated and if it is not then the referral will be returned.
  3. **ADDENDUM 24/5/21 – Due to the current waits for plain X-rays in some areas, an attached X-ray report will no longer be mandated. However, all referral letters must state that an X-ray has been done or that it has been requested. Please do attach reports if possible as they improve the efficiency of referral triage) **

A plain A-P X-ray of the pelvis report must accompany all hip referrals in all those over 55years of age (independent of suspected aetiology) or younger when OA is suspected.

The clinical indications for this are:

  1. to rule OA in or out as a differential for the patient's symptoms
  2. to ensure that deterioration in symptoms isn't due to potential Red Flag conditions e.g. avascular necrosis (an indication for expedited referral).
  3. deterioration in OA can result in more complex and time-consuming operations. If this is known, then the appropriate surgical list time can be allocated, hence avoiding cancellations of procedures later in the list

In addition, an up to date X-ray is essential to facilitate remote/virtual consultations

Please consider repeating an X-ray if a significant time has elapsed since the last one, or there has been a significant change/progression in your patient's symptoms. This will aid in remote/virtual consultations and help to avoid delay in diagnosis of differentials/red flag conditions.

Please note primary care is encouraged to follow In Shape for Surgery best practice which can be seen here.

Referral Instructions

Where the circumstances of treatment for an individual patient do not meet the criteria described above exceptional funding can be sought. Individual cases will be reviewed by the appropriate panel of the CCG upon receipt of a completed application from the patient's GP, consultant or clinician. Applications cannot be considered from patients personally.

Referral Forms

DRSS referral form

Supporting Information

GP Information

NICE OA Guideline

Patient Information

Patient Information for pain arising from the hip in adults

MyHealth patient information - Hip pain

Hip joint replacements

Hip replacement

Pathway Group

This guideline has been signed off on behalf of the NHS Devon Clinical Commissioning Group.

Publication date: July 2020

Updated: June 2021

Last updated: 24-06-2021

 

Home > Referral > Western locality > Musculoskeletal & Joint Disorders > Osteoarthritic Hip Pain Commissioned Pathway - Western locality

 

  • First line
  • Second line
  • Specialist
  • Hospital