Category
Threshold Criteria
Approximately 160,000 hip and knee replacement procedures are performed annually in England and Wales and there is a national trend towards increasing demand for these. Osteoarthritis is the most common indication for these joint replacement procedures.
Eligibility
| LLR ICB will only funded hip and knee replacement when all of the following criteria are met Pre Referral Criteria ·      Patient should have been seen in person and examined with regard to hip / knee to confirm the relevant pathology for this procedure. ·      Anaemia investigated and treated to bring Hb >115 in females and >130 in males. Surgery will not take place till these are corrected. ·      Diabetes controlled with HbA1c <8.5. Surgery is not possible unless treated.  ·      BMI <45. Referral should be made to the weight management Tier 3 service if BMI>35. Surgery is not offered for those with a BMI>45. ·      Hypertension treated with systolic <150mmHg ·      Pre-existing medical comorbidities optimised AND 3 months conservative treatment to include: o  an exercise programme, o  assistive devices e.g. walking aids where indicated o  discussion of weight management and smoking cessation as appropriate o   the use of pharmacological therapy to control symptoms AND ·      Confirmation that the patient is willing to undergo surgery AND ·      Evidence that the potential benefits and risks of surgery has been explained using a shared decision making tool |
| Referral Criteria (based on the classification of pain and functional limitation below) · Intense or severe symptomology AND/ OR · Moderate or severe functional limitations AND · Positive clinical examination findings in the specified joint AND . X-ray showing any radiological evidence of degenerative disease have been done within 6 months of referral. Conditions change over time and new diagnoses arise, so an xray needs to be contemporary to the referral. |
Urgent Referral without 3 months conservative treatment
| LLR ICB will only fund when the following criteria is met · Severe symptomology OR · Severe functional limitation AND . moderate, intense or severe symptomology |
Classification of symptomology and functional limitation
| SYMPTOMOLOGY |
| Slight – Infrequent pain – Pain on climbing/ descending stairs – Able to perform daily activities except those requiring great physical activity – Medication taken to control pain with no/ few side effects |
| Moderate – Occasional pain – Pain on walking or standing on level surfaces for half an hour – Some limitation of daily activities – Medication taken to control pain with no /few side effects |
| Intense – Almost continuous pain – Pain on walking short distances or standing on level surfaces for less than half an hour – Significant limitation of daily activities – Medication taken continuously to take effect – Occasional use of support systems e.g. walking aids |
| Severe – Continuous pain – Pain at rest – Constant significant limitation of daily activities – Continuous use of medication with no response or adverse effect – Constant use of support systems e.g. walking aid |
| FUNCTIONAL LIMITATION |
| 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 – Walking capacity of around half an hour – Aid e.g. walking stick needed |
| Severe – Largely or wholly incapacitated – Walking capacity of less than half an hour or unable to walk or bedridden – Constant use of aid e.g. walking stick, walker or wheelchair |
| Adapted from: Joint Planned Care Lead for North Kirklees and Wakefield CCG. NHS North Kirklees and Wakefield CCG Commissioning Policy. 2017 |
The Oxford Scoring Tool is optional and may be used within the clinical consultation to explore the impact on patients, their concerns and to review progression of the condition.
Appendix A illustrates the referral criteria.
Guidance
| https://pathways.nice.org.uk/pathways/osteoarthritis#path=view%3A/pathways/osteoarthritis/management-of-osteoarthritis.xml&content=view-quality-statement%3Aqualitystatements-referral-for-consideration-of-joint-surgery British Orthopaedic Association, Royal College of Surgeons. Commissioning Guide: Pain arising from the Hip in Adults. 2017. British Orthopaedic Association, Royal College of Surgeons. Commissioning Guide: Painful Osteoarthritis of the Knee. 2017. |
Appendix A
| ARP 53 Review Date: 2026 |
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