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Circle Bedfordshire Musculoskeletal Service:

Surgical Thresholds for procedures of Low Clinical Value, and management of these

conditions within the MSK Service January 2017

This guidance relates to the surgical thresholds for procedures of low clinical value (as determined

by the Bedfordshire & Hertfordshire clinical priorities forum and Cambridgeshire and Peterborough

Clinical Commissioning Group). It also demonstrates alternative management for patients who do

not meet the threshold criteria. The procedures of “low clinical value” include:

Carpal Tunnel Syndrome

Dupytrens contracture

Elective Total Hip Replacement (THR)

Elective Total Knee Replacement (TKR)

Ganglions

Hallux Valgus

Knee arthroscopy

Trigger finger

Non-acute spinal surgery

Shoulder pain (including referral to surgery)

Chronic hip pain

Pain procedures

The flow chart on the next page shows management of these conditions by the MSK service as

agreed with Bedfordshire CCG. Please see Appendix for more specific thresholds for each condition.

Please note the Fit for OP guidance is currently being reviewed by Bedfordshire CCG and this

is likely to result in amendments to these thresholds.

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Circle Bedfordshire Musculoskeletal Services: Management of Procedures of Low Clinical

Value

Referral with sufficient clinical information?

Returned to

referrer –

request for

more/missing

information

No

Referral received by Circle Bedfordshire MSK

Clinical triage by Extended Scope Practitioner

Does not meet the clinical

thresholds as set out in this

document and no alterative within

MSK service

Meets the clinical

thresholds as set out in

this document.

Returned to referrer with clinical

thresholds for information

Accepted and triaged to provider as

clinically appropriate Alternatives can be

offered.

If referrer feels patient meets

criteria –re-refer and provide more

information

If referral still rejected OR GP feels patient

does not meet criteria but there is a valid

reason for needing treatment – refer to

BCCG exceptions panel; if approved, GP to

send back to MSK service with referral and

evidence of approval

lll

Yes

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Management of the “low clinical value” conditions:

Condition/ Procedure

GP/ Self Management

Management in MSK Service

Summary of Surgical Thresholds (see checklists for more detail)

Carpal Tunnel Syndrome

Nocturnal neutral wrist splint / Steroid Injection

?corticosteroid injection Triage to surgery where meets criteria

Severe neurological symptoms at presentation: constant numbness or disabling pain with wasting of thenar muscles, and/or weakness of thumb muscles. OR Moderate symptoms (paraesthesia that interferes with activities of daily living or causes constant night waking, and/or reversible numbness and/or pain, perhaps by clenching and unclenching of fist or hand shaking) AND

Has not responded to a minimum of 3 months of conservative management, including a compliant trial of nocturnal neutral wrist splints

Consideration of one corticosteroid injection

Dupytrens contracture

Advice to passively stretch finger/ maintain movement

None –referrals not meeting surgical threshold will be rejected; Triage to surgery only where meets criteria

Moderate to severe form of disease with notable functional impairment AND

a) 30o or more fixed flexion at the metacarpophalangeal joint

OR b) 30o or more fixed flexion at the

proximal interphalagneal joint NB: this policy does not cover fast-track referral where there is diagnostic uncertainty. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently.

Elective Total Hip Replacement (THR)

Weight loss, adequate analgesia (including NSAIDs), advice to keep active and minimise weight-loading e.g. using walking aids, lifestyle adjustment where indicated If for surgical referral, GP to

Triage to Physio / Community MSK if not meeting surgical criteria. Those triaged to surgery will have discussion with Shared Decision Making team: if not meeting criteria / too young / do not want surgery, will be seen in MSK or

Patient has uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations (e.g. Oxford hip score <20) as defined in Table 1 below. AND Symptoms refractory to >6 months of non-surgical management of hip pain due to osteoarthritis, including:

Adequate medication – optimal tolerated doses of analgesia

Physiotherapy (guided exercise and muscle strengthening programmes or supervised physical therapy) – but NB: physiotherapy is ineffective in bone-on-bone osteoarthritis

Patient education to minimise weight-loading, activity

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arrange X-ray and BMI measurement – results to be sent with MSK referral

referred for physio. If appropriate for onward referral to surgery, offered choice of provider.

modification (avoid impact and excessive exercise) and lifestyle adjustment. Also consider appropriate walking aids +/- home adaptations

AND Where weight may restrict mobilisation post-operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of THR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m2 should be routinely offered referral to a weight management service to reduce these risks).

Elective Total Knee Replacement (TKR)

Weight loss, adequate analgesia (including NSAIDs), advice to keep active and minimise weight-loading e.g. using walking aids, lifestyle adjustment where indicated If for surgical referral, GP to arrange X-ray and BMI measurement – results to be sent with MSK referral

Triage to Physio / Community MSK if not meeting surgical criteria / if corticosteroid injection to be considered. Those triaged to surgery will have discussion with Shared Decision Making team: if not meeting criteria / too young / do not want surgery, will be seen in MSK or referred for physio. If appropriate for onward referral to surgery, offered choice of provider.

Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations (e.g. Oxford knee score <20) as defined in Table 1 below AND Symptoms refractory to >6 months of non-surgical management of knee pain due to osteoarthritis, including:

Adequate medication – optimal tolerated doses of analgesia

Physiotherapy (guided exercise and muscle strengthening programmes or supervised physical therapy) – but NB: physiotherapy may be ineffective in bone-on-bone osteoarthritis with no quadriceps wasting

Patient education to minimise weight-loading, activity modification (avoid impact and excessive exercise) and lifestyle adjustment. Also consider appropriate walking aids +/- home adaptations

AND Where weight may restrict mobilisation post-operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of TKR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m2 should be routinely offered referral to a weight management service to reduce these risks). Please note that patella resurfacing will not be routinely funded as evidence

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suggests there is no difference in clinical outcomes .

Ganglions If not meeting criteria – reassure. A proportion resolve spontaneously Lasting benefit of surgery is unclear – recurrence rates 1-40% depending on technique and site. Aspiration may be tried in Primary care (request hub support if required)


Significant skin breakdown, significant nail deformity or has required repeated episodes of drainage caused by distal interphalangeal joint mucous cysts OR Ganglion causes significant functional impairment and/or pain unrelieved by aspiration NB: This policy does not cover fast track referral where there is diagnostic uncertainty. A cystic swelling is likely to be a ganglion. However, a lump which is solid on USS or is not definitely cystic may be malignant. These lumps require MRI scan. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently.

Hallux Valgus

Foot wear advice, simple analgesia, non-surgical treatments e.g. bunion pads, splints, insoles, shields


Conservative management has failed AND severe pain or deformity (overriding toes) that causes significant functional impairment (preventing vital work, educational, domestic or carer responsibilities)

Knee Arthroscopy

Weight loss, adequate analgesia (including NSAIDs), advice to keep active and minimise weight-loading e.g. using walking aids, lifestyle adjustment where indicated GP to provide BMI with MSK referral.

Triage to Physio / Community MSK if not meeting surgical criteria and no previous treatment. Those triaged to surgery will have discussion with Shared Decision Making team: if not meeting criteria / do not want surgery, usually referred to physio (occasionally to Community MSK)

Completed 6 months of conservative treatment AND non-smoker or attempted smoking cessation AND normal BMI or attempted weight loss OR Mechanical locking AND worsening symptoms AND non-smoker or attempted smoking cessation AND normal BMI or attempted weight loss (to normal BMI or at least 10% of body weight) NB – this policy does not cover arthroscopy following trauma, septic arthritis (which would warrant referral to orthopaedic on-call team via A&E) or suspected malignancy, which would warrant urgent referral. N.B Arthroscopies for Osteoarthritis (and/or degenerative meniscal tears in patients over 50 will not be routinely funded)

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If appropriate for onward referral to surgery, and imaging completed, offered choice of provider.

Trigger finger

NSAIDs/ analgesia and OTC splints/ Corticosteroid Injection

See in MSK for corticosteroid injection(s)

Moderate symptoms at presentation: triggering with difficulty actively extending finger/need for passive finger extension OR loss of complete active flexion AND failure to respond to conservative treatment (≥2 corticosteroid injection) OR Severe symptoms (fixed contracture) that cannot be corrected with any other method OR Corticosteroid treatment is not suitable

Spinal surgery

Analgesia Triage to Physiotherapy (occasionally MSK) unless meet criteria for surgery

Lumbar disc conditions, duration >12 weeks, offered non-acute spinal surgery only under the following circumstances: 1. Surgical discectomy (standard or microdiscectomy) in selected patients with sciatica secondary to disc prolapse where conservative management has failed for at least 12 weeks; AND

if radicular pain has not responded to non-invasive treatment after 12 weeks; AND

the patient has been referred to Tier II musculoskeletal assessment service for assessment for spinal surgery or other non-invasive intervention; AND

the patient has lumbar radiculopathy with corresponding intervertebral disc prolapse on magnetic resonance imaging (MRI).

2. Severe spinal stenosis with symptoms of neurogenic claudication and the MRI shows significant canal stenosis 3. Spinal fusion may be considered for non-specific back pain if severe pain continues despite two years of active rehabilitation, cognitive intervention combined with exercises where available and the patient has been assessed by a specialist using appropriate scans NB – this policy does not cover acute back pain conditions such as fracture,

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dislocation, complications of tumour or infection and/or nerve root or spinal compression responsible for progressive neurological deficit; nor does it cover some of the causes of chronic back pain e.g. osteoporosis and related compression fractures, lumbar spine arthritis, infection, tumour, sagittal imbalance and spinal deformity. GPs should refer to secondary care directly for “red flag patients”, i.e. suspected cancer or cauda equina compression

Shoulder pain (including referral to surgery)

Self-care advice on modifying activities, use of NSAIDs and home exercises.

If self-management effective, patients should be referred for physiotherapy. Steroid injections will only be funded for patients whose pain is not controlled by NSAIDs or in whom the use of NSAIDs are contraindicated and other conservative management has failed. NB: in cases where injections are necessary to enable a patient to undergo physiotherapy, these may be used at the time of the first course of physiotherapy.

Patients with a traumatic injury or dislocation may be referred to Trauma and Orthopaedics. Where an MRA scan/ultrasound has demonstrated evidence of a full thickness rotator cuff tear or significant superior labral anterior-posterior tear (detachment of labrum), shoulder surgery will be funded.

For other conditions, before shoulder surgery will be funded, patients should have undergone further conservative management of:

3 months: partial thickness tears or minor superior labral anterior-posterior tears (fraying).

6 months: adhesive capsulitis, impingement syndrome, non-traumatic instability, calcific tendonitis, biceps tendonitis or acromioclavicular or glenohumeral arthritis*.

Shoulder arthroscopy will not be funded as a diagnostic tool.

* Where there is clear evidence of severe progressive osteoarthritis, patients may be referred before 6 months.

Chronic Hip Pain

Weight loss, adequate analgesia; simple home exercises

Triage to Physiotherapy. Where patient has not responded to Physiotherapy; triage to MSK –consider

Hip Resurfacing is a low priority treatment and will not be funded without exceptional case panel approval. Other arthroscopic or open hip surgery is a low priority treatment and will not be funded without exceptional case panel approval (including femoro-acetabular impingement, non-acute labral,

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diagnostics. Up to 3 corticosteroid injections will be funded for the treatment of hip osteoarthritis. Corticosteroid injections will be funded for the treatment of hip bursitis (trochanteric or other) as required.

ligamentum teres or abductor tendon tears, greater trochanteric pain syndrome/ trochanteric bursitis and osteoarthritis).

Pain Procedures

Pain management

Triage to MSK if no diagnostics; if chronic pain diagnosed and no recent change in symptoms triage to pain management.

Interventions should be part of an MDT package of care and not seen in isolation. Examples of Interventions where evidence is weak: Spinal cord stimulation. Intravenous regional sympathetic blockade with guanethidine. These are only funded in exceptional cases. The CCG will only fund: lumbar transforaminal and caudal epidural injections for patients with radicular pain due to herniated disc (sciatica) when the following criteria have been met: • The patient has radicular pain (below the knee for lower lumbar herniations; into the anterior thigh for upper lumbar herniations) consistent with the level of spinal involvement OR • there is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise – positive between 30o and 70o positive femoral tension sign) • Symptoms persist despite some non-operative treatment for at least 3 months (e.g. analgesia, physiotherapy). Further Epidural injections should only be provided as part of a comprehensive pain management programme. Facet joint injections Therapeutic The CCG will fund medial branch blocks for the management of cervical, thoracic and lumbar back pain as specified below: All conservative management options, (physiotherapy, exercise, pharmacotherapy

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including analgesia) have been tried and failed And the pain has resulted in moderate to significant impact on daily functioning The treatment of facet joint pain is provided as part of a comprehensive pain management programme Further facet joint injections will only be funded if the initial facet joint injection has had a proven therapeutic benefit and the patient is not suitable for Thermal Radiofrequency Denervation (RFD) or a Pain Management Programme (PMP). For those who are not suitable for RFD or PMP (patients with multiple co morbidities; cardiological and or respiratory dysfunction; cardiac pacemaker or other nerve stimulator; frail patients; elderly patients), up to two injections per year will be funded in line with the Pain Management Pathway for Chronic Facetal Pain. Intra articular injections will only be funded according to the criteria above. Note: (diagnostic facet joint injections used by spinal surgeons as part of a diagnostic pathway prior to making a decision to proceed to surgery will be funded). Radiofrequency facet joint denervation of the medial branch of the dorsal rami of the lumbar and cervical facet joints (medial branch neurotomy) will be funded in the following circumstances: • Patients aged over 18 • Non-radicular lumbar (all levels) or cervical (C3-4 and below) facet joint pain. • Failure of a one year trial of non-invasive therapy, such as medication and physiotherapy. • One anaesthetic diagnostic block, which must be of the medial branch of the dorsal rami innervating the target facet joint. A significant reduction in pain following the block during activities that normally generate pain should be demonstrated and recorded. The pain relief must be consistent with the expected duration of the anaesthetic block. • All procedures must be performed under fluoroscopy (x-ray guidance). NICE Guidance ID CG 88 on ‘Low Back Pain’ iv indicates that radiofrequency facet joint denervation is not recommended for those

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with back pain of less than a year’s duration. Thermal radiofrequency denervation is provided as part of a comprehensive Pain Management Programme (PMP). Cryoneurolysis or laser denervation will not be funded. Up to four facet joint denervation’s on one occasion (one treatment episode) will be funded.

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Classification of Pain Levels and Functional Limitations Table (to be used in conjunction with

THR and TKR guidelines)

Table 1: Classification of surgical criteria

Level of pain Definition

Slight

Sporadic Pain. Pain when climbing and descending stairs. Allows daily activities to be carried out (those requiring great physical

ability may be limited). Medication: Aspirin, Paracetamol or NSAIDs (Non Steroidal Anti-

Inflammatory Drugs) to control pain with no/few side effects.

Moderate

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 pain with no/few

side effects.

Intense

Pain of almost continuous nature. Pain when walking short distances on level surfaces or standing less than

half an hour. Activities of daily living (ADL)* significantly limited. Continuous use of NSAID for treatment to take effect. Requires the sporadic use of support systems (walking stick, crutches).

Severe

Continuous pain. Pain when resting. Activities of daily living* 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).

Functional

limitations Definition

Minor Functional capacity adequate to conduct normal activities and self-care. Walking capacity of about 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/walking stick are needed.

Severe Largely or wholly incapacitated. Walking capacity of less than half an hour or unable to walk or bedridden. Aids such as a cane, a walker or wheelchair are required.

*ADL includes activities such as meal preparation, laundry, housekeeping, shopping, using the

phones, driving or using public transport.

Useful site for further information for GPs and patients: http://www.nhsinform.co.uk/msk

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Bedfordshire Musculoskeletal Services: Procedures of Low Clinical Value – Appendix

These are checklists for each of the MSK procedures of low clinical value based on the

Cambridgeshire and Peterborough Clinical Commissioning Group.

Carpal Tunnel Syndrome (CTS) Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria – patients should meet the following criteria:

tick box(s) as appropriate

Severe neurological symptoms at presentation: constant numbness or disabling pain with wasting of thenar muscles, and/or weakness of thumb muscles.

OR Moderate symptoms (paraesthesia that interferes with activities of daily living or causes constant night waking, and/or reversible numbness and/or pain, perhaps by clenching and unclenching of fist or hand shaking)

AND

Has not responded to a minimum of 3 months of conservative management, including a compliant trial of nocturnal neutral wrist splints.

Consideration of one corticosteroid injection.

AND Patient is a non-smoker

OR

Patient has been advised of the surgical and post-surgical risks associated with smoking, referred to a smoking cessation service where appropriate and attempted to stop smoking 8 to 12 weeks before the operation.

Procedure needed to be performed outside the policy criteria. Please give clinical indication: ………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………………………………………

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Definition: Carpal Tunnel Syndrome (CTS) is a condition characterised by attacks of pain, numbness or tingling in the distribution of the median nerve (thumb, index, middle and half of ring finger). It is caused by compression of the median nerve as it passes under the ligament that lies across the front of the wrist. 1 Policy criteria: The CCG will ONLY fund Carpal Tunnel Surgery in patients diagnosed with Carpal Tunnel Syndrome according to the following criteria:

The patient has severe neurological symptoms at presentation, for example altered sensation, muscle wasting or weakness of thenar abduction. OR

The patient has moderate symptoms as defined below AND has not responded to a minimum of 3 months of conservative management, including local corticosteroid injections and a compliant trial of nocturnal neutral wrist splints.

Classification for Severity of Carpal Tunnel Syndrome: 2 Mild: Intermittent paraesthesia with or without pain that may be nocturnal, or occurs

with a certain hand position. Moderate: Paraesthesia that interferes with activities of daily living or causes constant night

waking. And/Or reversible numbness and/or pain (perhaps by clenching and unclenching of fist or hand shaking).

Severe: Constant numbness or disabling pain with wasting of thenar muscles. And/Or weakness of thumb muscles (Abductor Pollicis Brevis and Opponens Pollicis).

Note: Patients who smoke should have attempted to stop smoking 8 to 12 weeks before the operation to reduce the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. 3, 4 Rationale and Evidence

Untreated Carpal Tunnel Syndrome has been shown to resolve or significantly improve in up to 49% of cases.5

Non-surgical treatment, including oral steroids, splinting, ultrasound, yoga and carpal bone mobilisation show short-term benefit compared with placebo or other non-surgical interventions. 6

Conservative treatment is preferred in mild to moderate cases and surgical treatment is mainly applied in severe cases including nerve denervation. Surgical treatment is indicated in cases where initial conservative management has failed. 7

Corticosteroid injection has been shown to be effective at one month, but the effect decreases by 30% at one year. 8

Local corticosteroid injection is effective in relieving symptoms at one month and is more effective than oral steroids. 9

When steroid injections were compared to splinting, injections were not as effective at one year while splints worn every night were shown to be effective for symptom relief and nerve conduction. 10

Injected steroids have been compared to surgery - one study showed greater improvement in the steroid group for nocturnal paraesthesia at three months, but equivalence at 6 and 12 months 11 whilst another study showed greater symptomatic improvement with surgery at 20 weeks. 12

Another review showed surgery is better than splinting for symptom relief at three months and one year. 13 One particular study showed improved outcomes with surgery at 3 months and 18 months. 41% of the splinting group had undergone surgery by 18 months. 14

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In terms of which surgery to perform, a Cochrane Review found no strong evidence for replacement of standard open carpal tunnel release (OCTR) by alternative surgical procedures although it reports that endoscopic carpal tunnel release may enable people to return to work and resume daily life activities on average one week earlier than OCTR. 15

Estimated number of people affected:

Annual incidence of 139 cases per 100,000 females and 67 per 100,000 males. 16 CTS is more common in middle age (older than 40 years) 17 and in women (during pregnancy and menopause). 1

References: 1. Clinical Knowledge Summary (Sept 2012) [Online] Available from: http://cks.nice.org.uk/carpal-tunnel-syndrome#!topicsummary. 2. British Society for Surgery of the Hand (2011) BSSH Evidence for Surgical Treatment (BEST): Carpal Tunnel Syndrome (CTS) [Online] Available from: http://www.bssh.ac.uk/education/guidelines/carpal_tunnel_syndrome.pdf 3. C Furlong. Preoperative Smoking Cessation: A Model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A report by London Health Observatory. September 2005. 4. S Hajioff, M Bhatti. Pre-operative smoking cessation therapy in NCL. A case of short-term gain for long-term gain? 5. Padua L, Padua R, et al. (2001) Multiperspective follow-up of untreated carpal tunnel syndrome: a multicenter study. Neurology. 2001 Jun 12;56(11):1459-66. 6. O’Connor D, et al. (2003). Non-surgical treatment (other than steroid injection) for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003219. DOI: 10.1002/14651858.CD003219. 7. Huisstede BM, et al. (2010). Carpal Tunnel Syndrome. Part II:Effectiveness of Surgical Treatments- A Systematic Review. Arch Phys Med Rehabil 2010;91 1004-1024. 8. Dammers J, et al. (1999). Injection with methylprednisolone proximal to the carpal tunnel: randomised double blind trial BMJ 1999 319: 884-8. 9. Marshall S C, et al. (2007) Local corticosteroid injection for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD001554. DOI: 10.1002/14651858.CD001554.pub2. 10. Sevim S, et al. (2004). A Long-term effectiveness of steroid injections and splinting in mild and moderate carpal tunnel syndrome. Neurol Sci. 2004 Jun;25(2):48-52. 11. Hui A, et al. (2005). A randomised controlled trial of surgery vs steroid injection for carpal tunnel syndrome Neurology, June 28, 2005; 64(12): 2074 – 2078. 12. Ly-Pen D, Andreu J L, et al. (2005). Surgical decompression versus local steroid injection in carpal tunnel syndrome: a one-year, prospective, randomised, open, controlled clinical trial. Arthritis Rheum 2005;52: 612-9. 13. Verdugo R J, et al. (2008). Surgical versus non-surgical treatment for carpal tunnel syndrome. Cochrane, Database of Systematic Reviews 2008, Issue 4. Art. No.: CD001552. DOI: 10.1002/14651858.CD001552.pub2. 14. Gerritsen A A, et al. (2002). Splinting vs surgery in the treatment of carpal tunnel syndrome: a randomised controlled trial. JAMA 2002 Sep 11;288(10):1245-51. 15. Scholten R, et al. (2007). Surgical treatment options for carpal tunnel syndrome. Cochrane Database of Systematic Reviews 2007, Issue 4.Art.No.:CD003905.DOI: 10.1002/14651858.CD003905.pub3.

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Dupytrens Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria – patients should meet the following criteria:

Note: The policy and this referral proforma do not cover fast track referral where there is diagnostic uncertainty. In particular any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently.


Moderate to severe form of disease with notable functional impairment

AND 30o or more fixed flexion at the metacarpophalangeal joint

OR

30o or more fixed flexion at the proximal interphalagneal joint


OR


Procedure needed to be performed outside the policy criteria. Please give clinical indication: ........................................................................................................ ………………

…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

……………………………………………………

Definition:

Dupuytren’s Contracture is defined as a benign proliferative (rapidly growing) disease that occurs

in the fascia of the palms and fingers leading to the formation of nodules, cords and resulting in

contractures. 1 A clawing deformity of the fingers develops, particularly the little and ring

fingers.

Policy criteria:

The CCG will ONLY fund the surgical treatment of Dupuytren’s Contracture according to the following criteria:

The patient has a moderate to severe form of disease as defined below. Classification for Severity of Dupuytren’s Contracture: 2 Mild: No functional impairment Contractures less than 30o at metacarpophalangeal joints (MCPJ) Moderate: Notable functional impairment 30-60o fixed flexion at the MCPJ and less than 30o at

the proximal interphalagneal joint (PIPJ) Severe: Fixed flexion greater than 60o at the MCPJ and greater than 30o at the PIPJ

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Note 1: Patients who smoke should have attempted to stop smoking 8 to12 weeks before the operation to reduce the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. 3, 4 Note 2: This policy does not cover fast track referral where there is diagnostic uncertainty. In

particular, any lump which is painful, history of increasing size and is deep to the fascia

should be referred urgently.

Rationale and Evidence:

Non-surgical treatments such as Clostridial collagenase injection, Percutaneous needle fasciotomies (PNF) and Radiation Therapy have been shown to have some benefit, but there is no clear evidence that outcomes are better than surgical interventions. 5-7

It is suggested that surgery should be performed on an affected MCPJ if the contracture is 30° or greater and if there is involvement of the PIPJ. 8

A retrospective audit indicated that surgery for Dupuytren’s disease is successful in achieving full or almost full correction in 75% of cases, but recurrence rate in cases ranged from 26-80%. 9, 10

The National Institute for Health and Clinical Excellence (NICE) reviewed evidence for the practice of percutaneous needle fasciotomies (PNF) as a treatment option - it was shown to not be as effective in preventing recurrence as surgery, but is a good option because low complication profile allowed the procedure to be repeated. 11

NICE guidelines on Radiation Therapy state that there is no strong evidence for efficacy yet, but there are no concerns about safety at the moment and should only be used by experienced senior clinicians. 12

Dupuytren’s Contracture is common and the prevalence ranges from 0.2 – 30% in the UK, varying with geographical location. The disease more commonly affects white people of European descent, men and the elderly. 13


Dupuytren’s Contracture is common and the prevalence ranges from 0.2 – 30% in the UK, varying

with geographical location. The disease more commonly affects white people of European

descent, men and the elderly. 13

References:

1. McGrouther D A. (1998). Dupuytren’s contracture. In D P Green, R N Hotchkiss and W C Pederson (Eds) Operative HAND Surgery, Vol 1, 4th edition. New York: Churchill Livingstone, 1998. 563-591. 2. British Society for Surgery of the Hand (2010) BSSH Evidence for Surgical Treatment (BEST): Dupuytren’s contracture [Online] Available from: http://www.bssh.ac.uk/education/guidelines/dd_guidelines.pdf . 3. C Furlong. Preoperative Smoking Cessation: A Model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A report by London Health Observatory. September 2005. 4. S Hajioff, M Bhatti. Pre-operative smoking cessation therapy in NCL. A case of short-term gain for long-term gain? 5. Badalamente M A, Hurst L C. (2000). Enzyme injection as nonsurgical treatment of Dupuytren's disease. J Hand Surg [Am] 2000: 25;629-636. 6. Foucher G, Medina J, Navarro R. (2003). Percutaneous needle aponeurotomy: complications and results. J Hand Surg Br. Oct 2003;28(5):427-31. 7. Rayan G M. (2008). Nonoperative Treatment of Dupuytren's Disease. J of Hand Surgery[Am].Volume 33, Issue 7, September 2008,1208-1210. 8. Lee S, Baytion M. (2006). Dupuytren contracture. E-Medicine. December 2006.

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9. Dias J J, Braybrooke J. (2006). Dupuytren's contracture: an audit of the outcomes of surgery. J Hand Surg [Br]. 2006 Oct;31(5):514-21. Epub 2006 Jul 11. 10. Hurst L C, Badalamente MA. (1999). Nonoperative treatment of Dupuytren's disease. Hand Clin 1999 Feb;15(1):97-107. 11. NICE guidelines 2004 for Needle Fasciotomy in Dupuytren’s Contracture (reviewed in 2011) http://www.nice.org.uk/guidance/IPG43. 12. NICE guidelines 2010 for Radiation therapy for early Dupuytren's disease (reviewed in 2011) http://guidance.nice.org.uk/IPG368/PublicInfo/pdf/English. 13. Clinical Knowledge Summaries- Dupuytren’s Disease (May 2010). [Online] Available from: http://cks.nice.org.uk/dupuytrens-disease#!backgroundsub:3.

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Total Hip Replacement Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum This policy covers referrals for primary elective total hip replacement (THR). This policy does not affect criteria for Immediate / Urgent Referral to Orthopaedic Services in respect of:

Evidence of infection in the hip joint.

Conditions (such as AVN-avascularnecrosis) leading to a rapid deterioration in the joint where delay to treatment would be unreasonable.

The CCG will ONLY fund referral for consideration of THR in patients meeting the following criteria.


The initial non-surgical (conservative) management of hip pain due to osteoarthritis has been provided for at least 6 months, including:

Medication (eg adequate doses of non-steroidal anti-inflammatory drugs (NSAIDs) and analgesics).

AND

Physiotherapy (guided exercise and muscle strengthening programmes or supervised physical therapy).

AND

Patient education (to minimise weight-loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment.

AND Symptoms are refractory to at least 6 months of conservative management as above.

AND Patient has uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations as defined in ‘Table 1’ below.

AND Where weight may restrict mobilisation post operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of THR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m2 should be routinely offered referral to a weight management service to reduce these risks).


OR


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…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

……………………………………………………

Definition:

This policy covers referrals for primary electiveI total hip replacement (THR)I. Total hip

replacement (THR) generally involves removal of the head of the femur (thigh bone) and its

replacement with a metal or ceramic prosthesis that fits into the remaining bone. The ball end of

the artificial femur then fits into a cup-like socket (acetabular cup) that is installed in the

patient’s pelvis.

Policy:

The CCG will ONLY fund referral for consideration of THR in patients meeting the following

criteria. It is presumed that all referrals meet these criteria prior to referral unless exceptional,

in which case the referral should document explicitly the reason for exceptional circumstances.

1. Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations which have failed a reasonable period of maximal conservative treatment (often>3/12) as defined in Table 1 above (*Oxford hip score < 20 may guide the referring clinician however should not be considered an absolute)

AND

2. Symptoms refractory to at least 6 months conservative management for the condition. (*Oxford Hip Score http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html)

PRIOR CONSERVATIVE MANAGEMENT MUST INCLUDE ALL OF THE FOLLOWING:

Medication o The patient should be taking Optimal tolerated doses of analgesia. Patients should

have gained an understanding of their correct uses (Paracetamol, NSAIDs or Opioid analgesics).

AND

Physiotherapy o NICE ‘core’ treatments of either guided exercise and muscle strengthening

programmes or of supervised physical therapy must have been given. Note: Physiotherapy is ineffective in bone on bone osteoarthritis. AND

Patient Education and Orthosis o Patient education such as elimination of damaging influence on hips (by reducing

weight loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment.

o Patients must have been advised about, and/or assessed for, clinically appropriate walking aids and home adaptations.

AND

http://www.orthopaedicscore.com/scorepages/oxford_hip_score.html

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Lifestyle improvement is paramount prior to major surgery o It is strongly advised to reduce BMI to less than 35 kg/m2 as this may reduce

complications and improve outcomes. Patients with a BMI greater than 35 kg/m2 should be routinely offered referral to a weight management service to reduce these risks.

o Patients who smoke should have attempted to stop smoking 8 to 12 weeks before referral to reduce the risk of surgery and post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks.

Patients’ (and carers’ as appropriate) expectations of surgery, and the likely degree of additional benefit that may be obtained from surgery compared with continuing conservative management, must have been discussed in primary/intermediate care. Patients must have been given an opportunity in primary/intermediate care to complete the Decision Aid tool on http://sdm.rightcare.nhs.uk/pda/, http://sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-hip/ This policy does not affect criteria for Immediate / Urgent Referral to Orthopaedic Services in respect of:

Evidence of infection in the hip joint.

Conditions (such as AVN-avascular necrosis) leading to a rapid deterioration in the joint where delay to treatment would be unreasonable.

Rationale and evidence: Purpose of THR and patient selection NICE IPG 363 states that current evidence on the safety and efficacy of minimally invasive total hip replacement appears adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit. Patient selection should be done by surgeons and their teams who can offer both conventional and minimally invasive total hip replacement. Morbidly obese patients have a 65.5% increase in the revision rates for THR versus the normal BMI group (18.5–25)9. Numbers of people affected: The prevalence of all cause hip disease severe enough to require surgery has been estimated at 15.2 per 1,000 people aged 35 to 85 years of age12. It has been estimated, based on radiographic evidence, that between 10% and 25% of people over the age of 55 have osteoarthritis of the hip. Symptomatic hip osteoarthritis has been estimated to affect between 0.7% and 4.4% of adults. References: 1. Ipswich and East Suffolk CCG Low Priority Procedure- Policy T18a: Hip Replacement. January 2011. 2. National Institute of Clinical Excellence. Primary Care Referral Guidelines for Common Conditions. NICE 2003; London. 3. National Institute of Clinical Excellence. CG59 Osteoarthritis. February 2008. 4. Horizon Scan on Hip Replacement Surgery. ECRI Evidence-based Practice Centre Agency for healthcare Research and Quality .USA December 22, 2006 http://www.cms.gov/determinationprocess/downloads/id44TA.pdf 5. National Institute of Clinical Excellence. Primary care referral guidelines for common conditions. NICE 2003; London. 6. National Institute of Clinical Excellence. Minimally invasive total hip replacement. NICE IPG 363;2010. http://www.nice.org.uk/nicemedia/live/11159/51306/51306.pdf

http://sdm.rightcare.nhs.uk/pda/

http://sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-hip/

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7. The Musculoskeletal Services Framework – A joint responsibility: doing it differently. Department of Health, 2006. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_4138412.pdf 8. 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. 9. Culliford D, Maskell J et al. A population-based survival analysis describing the association of BMI on time to revision for total hip and knee replacement: results from the UK GPRD. BMJ open 2013. 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. http://www.nice.org.uk/nicemedia/live/11000/30365/30365.pdf 11. Azodi O S, 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. Furlong C. Preoperative Smoking Cessation: A model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A Report by the London Health Observatory, 2005. 13. NICE Guidance on the use of metal on metal hip resurfacing arthroplasty. Technology Appraisal Guidance No 44, 2002. NICE guidance on selection of Prostheses for Primary Total Hip Replacement. Technology Appraisal Guidance No 02, 2000. http://www.nice.org.uk/nicemedia/pdf/Guidance_on_the_selection_of_hip_prostheses.pdf http://www.nice.org.uk/nicemedia/live/11462/32393/32393.pdf 14. Quintana J M, 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: 1200-1208. 15. Dawson J, Fitzpatrick R, Fletcher J and Wilson R. Osteoarthritis Affecting the Hip and Knee. In Health Care Needs Assessment: The epidemiologically based needs assessment reviews, Second Edition, Volume 1. Editors; Stevens A, Raftery J, Mant J and Simpson S. Radcliff, 2004; Radcliffe Publishing Oxford and San Francisco.

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Total Knee Replacement Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum This policy covers referrals for primary elective total knee replacement (TKR) to replace some or all of the components of the knee joint with a synthetic implant, and repair damaged weight bearing surfaces. The policy does not affect criteria for Immediate/Urgent Referral to Orthopaedic Services in respect of:

Evidence of infection in the knee joint.

Symptoms indicating a rapid deterioration in the joint.

Persistent symptoms that are causing severe disability. The CCG will ONLY fund referral for consideration of TKR in patients meeting ALL the following criteria.


Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and moderate functional limitations (eg *Oxford knee score <20) as defined in Table 1 above. Evidence of radiological features of disease; severe, moderate or mild if functional issues are severe enough

AND The initial non-surgical (conservative) management of knee pain due to osteoarthritis has been provided for at least 6 months, including: Medication:

Optimum tolerated doses of analgesic (Paracetamol, NSAIDs or Opioid analgesics).

Intra-articular corticosteroid injections should be considered as an adjunct to analgesia.

AND Physiotherapy:

NICE ‘core’ treatments of either guided exercise and muscle strengthening programmes or of supervised physical therapy.

AND Patient Education:

such as elimination of damaging influence on knees (by reducing weight loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment;

advice about, and/or assessment for, clinically appropriate walking aids and home adaptations.

AND Symptoms are refractory to at least 6 months of conservative management as above.

AND Where weight may restrict mobilisation post operatively or place pressure on the new joint, patient has been advised of the risks (complications, long-term failure of TKR, bleeding and post-operative thromboembolism) and attempted to lose weight (patients with a BMI greater than 35 kg/m2 should be routinely offered referral to a weight management service to reduce these risks).

AND Patient is a non-smoker.

OR

Patient has been advised of the surgical and post-surgical risks associated with smoking, referred to a smoking cessation

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service where appropriate and attempted to stop smoking 8 to 12 weeks before the operation.

(*Oxford Knee Score http://www.orthopaedicscore.com/scorepages/oxford_knee_score.html


…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

……………………………………………………

Definition:

This policy covers referrals for primary electivei total knee replacement (TKR)i to replace some

or all of the components of the knee joint with a synthetic implant, and repair damaged weight

bearing surfaces.

Policy:

The CCG will ONLY fund referral for consideration of TKR in patients meeting the following

criteria. It is presumed that all referrals meet these criteria prior to referral unless exceptional in

which case the referral should document explicitly the reason for exceptional circumstances.

1. Uncontrolled, intense, persistent pain resulting in substantial impact on quality of life and

moderate functional limitations which have failed a reasonable period of maximal conservative treatment (often>3/12) as defined in Table 1 above (Oxford knee score < 20 may guide the referring clinician however should not be considered an absolute) AND

2. Symptoms refractory to at least 6 months conservative management for the condition.

PRIOR CONSERVATIVE MANAGEMENT MUST INCLUDE ALL OF THE FOLLOWING

Medication o Optimum tolerated doses of analgesic should be used and patients should have

gained an understanding of how to use oral or topical analgesics (Paracetamol, NSAIDs or Opioid analgesics).

o Intra-articular corticosteroid injections should be considered as an adjunct to analgesia.

AND

Physiotherapy o NICE “core” treatments of either guided exercise and muscle strengthening

programmes or of supervised physical therapy must have been given. Note: Physiotherapy may be ineffective in bone on bone osteoarthritis with no

quadriceps wasting.

AND

Patient Education and Orthosis

http://www.orthopaedicscore.com/scorepages/oxford_knee_score.html

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o Patient education such as elimination of damaging influence on knees (by reducing weight loading), activity modification (avoid impact and excessive exercise) and lifestyle adjustment.

o Patients must have been advised about, and/or assessed for, clinically appropriate walking aids and home adaptations.

AND

Lifestyle improvement is paramount prior to major surgery o It is strongly advised to reduce BMI to less than 35 kg/m2 as this may reduce

complications and improve outcomes. Patients with a BMI greater than 35 kg/m2 should be routinely offered referral to a weight management service to reduce these risks.

o Patients who smoke should have attempted to stop smoking 8 to 12 weeks before referral to reduce the risk of surgery and post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks.

Patients’ (and carers’ as appropriate) expectations of surgery, and the likely degree of additional benefit that may be obtained from surgery compared with continuing conservative management, must have been discussed in primary/intermediate care. Patients must have been given an opportunity in primary/intermediate care to complete the Decision Aid tool on http://sdm.rightcare.nhs.uk/pda/,http://sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-knee/ The policy does not affect criteria for Immediate/Urgent Referral to Orthopaedic Services in respect of:

Evidence of infection in the knee joint.

Symptoms indicating a rapid deterioration in the joint.

Persistent symptoms that are causing severe disability. Rationale and evidence: Purpose of TKR and patient selection TKR is most commonly performed for knee joint failure caused by osteoarthritis (OA); other indications include rheumatoid arthritis (RA), juvenile rheumatoid arthritis, osteonecrosis and other types of inflammatory arthritis. The aims of TKR are relief of pain and improvement in function. TKR can be very successful for selected patients with over 90% of TKRs still in place and functioning well at 10 to 15 years after surgery. Optimum selection of patients is uncertain and conservative management including supervised/group exercise and physical therapy is effective for the majority affected by osteoarthritis. Numbers of people affected: The prevalence of symptomatic knee osteoarthritis has been estimated at 6.1% of people aged over 30 years and 7.5% of people aged over 55. It has been estimated, based on radiographic evidence, that between 14% and 34% of people over the age of 55 have osteoarthritis of the knee. Knee osteoarthritis is strongly associated with obesity and gender (chiefly affecting women) and is related to types of work that involve frequent squatting. References: 1. Bedfordshire and Hertfordshire Priorities Forum Statement Number 33: Referral criteria for patients from primary care presenting with knee pain due to osteoarthritis and clinical threshold for elective primary knee replacement surgery, February 2007. 2. Ipswich and East Suffolk CCG Low Priority Procedure- Policy T18b: Knee Replacement. January 2011.

http://sdm.rightcare.nhs.uk/pda/,http:/sdm.rightcare.nhs.uk/pda/osteoarthritis-of-the-knee/

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3. National Institute of Clinical Excellence. Primary Care Referral Guidelines for Common Conditions. NICE 2003; London. 4. National Institute of Clinical Excellence. CG59 Osteoarthritis. February 2008. 5. British Orthopaedic Association. Total Knee Replacement; A Guide to Best Practice. 2001. 6. The Musculoskeletal Services Framework – A joint responsibility: doing it differently. Department of Health, 2006. 7. Quintana J M, 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: 220-226. 8. Furlong C. Preoperative Smoking Cessation: A model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A Report by the London Health Observatory, 2005. 9. Culliford D, Maskell J et al. A population-based survival analysis describing the association of BMI on time to revision for total hip and knee replacement: results from the UK GPRD. BMJ open 2013. 10. Amin A K, Clayton R A E, Patton J T, Gaston M, Cook, R E and Brenkel IJ. Total knee replacement in morbidly obese patients results of a prospective, matched study. Journal of Bone and Joint Surgery British, 2006; 88: 1321-1326. 11. Gillespie G N and Porteous A J. Obesity and knee arthroplasty. The Knee, 2007; 14: 81-86. 12. Martin K, Fontain K R, Nicklas B J, Dennis K E, Goldberg A P and Hochberg M C. Weight loss and exercise walking reduce pain and improve physical functioning in overweight postmenopausal women with knee osteoarthritis. Journal of Clinical Rheumatology, 2001; 7: 219-223. 13. 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. 14. Christensen R, Bartels E M, Astrup A and Bliddal H. Effect of weight reduction in obese patients diagnosed with knee osteoarthritis: a systematic review and meta analyses. Annals of the Rheumatic Diseases, 2007; 66: 433-439. 15. Dawson J, Fitzpatrick R, Fletcher J and Wilson R. Osteoarthritis Affecting the Hip and Knee. In Health Care Needs Assessment: The epidemiologically based needs assessment reviews, Second Edition, Volume 1. Editors; Stevens A, Raftery J, Mant J and Simpson S. Radcliff, 2004; Radcliffe Publishing Oxford and San Francisco. 16. Black’s Medical Dictionary. 42nd Edition. A & C Black. London 2010. 17. National Institute of Clinical Excellence. Minimally invasive total knee replacement. NICE IPG 345;2010.

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Ganglion Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria – patients should meet the following criteria: Note: The policy and this policy proforma do not cover fast track referral where there is diagnostic uncertainty. A cystic swelling is likely to be a ganglion. However, a lump which is solid on USS or is not definitely cystic may be malignant. These lumps require MRI scan. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently.


Significant skin breakdown, significant nail deformity or has required repeated episodes of drainage caused by distal interphalangeal joint mucous cysts

OR Ganglion causes significant functional impairment and/or pain unrelieved by aspiration.


OR



…………………………………………………………………………………………………………………………………………………………

…………………………………………………………………………………………………………………………………………………………

……………………………………………………

Definition: A ganglion is a benign fluid-filled cyst that forms around joints or tendons. It has been reported to affect almost every joint in the wrist and hand, but can also affect the lower limb joints. 1 Policy: The CCG will ONLY fund surgical removal of ganglia according to the following criteria:

The patient presents with a significant skin breakdown, significant nail deformity or has required repeated episodes of drainage caused by distal interphalangeal joint mucous cysts (risk of septic arthritis). OR

The ganglion is causing significant functional impairment unrelieved by aspiration.

And it has been discussed with patients frequency of spontaneous resolution AND likelihood of recurrence AND possible complications of treatment

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Note 1: Patients who smoke should have attempted to stop smoking 8 to12 weeks before the operation to reduce the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. 2, 3 Note 2: This policy does not cover fast track referral where there is diagnostic uncertainty. A cystic swelling is likely to be a ganglion. However, a lump which is solid on USS or is not definitely cystic may be malignant. These lumps require MRI scan. In particular, any lump which is painful, history of increasing size and is deep to the fascia should be referred urgently. Rationale and evidence:

Some proportion of dorsal and volar ganglia have been shown to resolve spontaneously in a 6-year prospective study. 4

Up to three serial aspirations may be needed to alleviate symptoms and reduce recurrence rates. 5

Recurrence rates after surgery vary from 1% to 40% depending on surgical technique and site of ganglion. 6

There is no clear evidence to suggest that steroid injection coupled with aspiration can affect recurrence rate. 7

Estimated number of people affected: Prevalence of ganglia is estimated to be around 25 to 43 per 100 000 population. 8 Ganglion cysts affect anyone, but are commonly seen in women and in the second to fourth decades of life. In the paediatric population, the majority of ganglia resolve in less than a year. 9 Ganglion is the second commonest reason for referral to hand units. 1 References: 1. British Society for Surgery of the Hand (2010) BSSH Evidence for Surgical Treatment (BEST): Wrist ganglion [Online] Available from: http://www.bssh.ac.uk/education/guidelines/ganglion.pdf. 2. C Furlong. Preoperative Smoking Cessation: A Model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A report by London Health Observatory. September 2005. 3. S Hajioff, M Bhatti. Pre-operative smoking cessation therapy in NCL. A case of short-term gain for long-term gain? 4. Dias J J, et al. (2007). The natural history of untreated dorsal wrist ganglia and patient reported outcome 6 years after intervention. The Journal of hand surgery (European volume). 2007 vol. 32 (5) pp. 502-8. 5. Oni J A. (1992). Treatment of ganglia by aspiration alone. Journal of hand surgery (Br). 1992 vol. 17 (6) pp. 660. 6. Burke F D, et al. (2003). Primary care referral protocol for wrist ganglia. Postgrad Med J 2003;79:329–331 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1742717/pdf/v079p00329.pdf). 7. Varley G W et al. (1997). Conservative management of wrist ganglia. Aspiration versus steroid infiltration. Journal of hand surgery (Br). 1997 vol. 22 (5) pp. 636-7. 8. Janzon L, Niechajev I A. (1981). Wrist ganglia. Incidence and recurrence rate after operation. Scand J Plast Reconstr Surg. 1981;15(1):53-6. 9. Coffey M J, et al. (2008). Pediatric Ganglion Cysts of the hand and wrist: an epidemiologic analysis. Hand (NY). 2008 Dec;3(4) pp. 359-62.

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Knee Arthroscopy Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria - patients should meet one of the following criteria:


Patient has either:

A Trauma, septic arthritis or suspected malignancy NB: THESE PATIENTS SHOULD BE REFERRED DIRECTLY TO A&E / ORTHOPAEDIC ON-CALL, NOT VIA MSK SERVICE

OR B Completed 12 months of conservative treatment AND non-smoker or attempted smoking cessation AND normal BMI or attempted weight loss (to normal BMI or at least 10% of body weight)

OR C Mechanical locking AND worsening symptoms AND non-smoker or attempted smoking cessation AND normal BMI or attempted weight loss


…………………………………………………………………………………………………………………………………………………………

…………………………

N.B Arthroscopies for Osteoarthritis (and/or degenerative meniscal tears in patients over 50 will not be routinely funded) Note: Patients who smoke should have attempted to stop smoking 8 to 12 weeks before the

operation and should be offered referral to the appropriate smoking cessation

services.

Patients who are overweight or obese should be offered referral to the appropriate

weight management service.

Scope:

This policy covers the use of knee arthroscopy as a surgical intervention or diagnostic tool. It does

not cover arthroscopy following trauma, septic arthritis or suspected malignancy.

Policy: Primary/Community Care Where evidence is provided that a comprehensive course of conservative treatment has been tried for 12 months and failed, patients can be referred for specialist consultation. However, where patients have mechanical locking or worsening symptoms, these patients may be referred before completing 12 months of conservative treatment. Referral for MRI scans should only be done by specialist consultants in secondary care. Secondary Care Where a competent clinical examination or MRI scan has demonstrated clear evidence of an internal joint derangement, knee arthroscopy will be funded. However, knee arthroscopy will not be funded for:

1. procedures that are not recommended by NICE, eg lavage;

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2. procedures restricted by NICE, eg knee meniscus replacement with biodegradable scaffold, mosaicplasty, autologous chondrocyte implantation and trochleoplasty for patellar instability;

3. debridement, except in cases where there is a clear history of mechanical locking; 4. use as a diagnostic tool, except in cases where there is on-going diagnostic uncertainty

following both clinical examination and non-invasive imaging procedures (eg MRI) conducted by specialists.

Rationale and evidence: No Referral before 12 months of Conservative Treatment For patients with non-traumatic knee injury, evidence shows that, on average, conservative treatment is as effective as arthroscopic knee surgery for some procedures: Partial meniscectomy surgery showed no advantage over sham in one RCT of patients aged 35-65 years with degenerative meniscal tears without osteoarthritis 1 and no advantage over physical therapy in two RCTs of older patients (>45 years) with osteoarthritis. 2, 3 In RCTs of young patients (mean age ~20 years) with a first occurrence of patellar dislocation, there was no conclusive advantage of surgical treatments compared with non-surgical treatments. 4 In an RCT of patients with patellofemoral pain syndrome (18-40 years), mixed arthroscopic procedures and exercise resulted in equivalent improvements compared with exercise alone. 6 Although rates of post-operative complications are generally low7 higher rates have been observed in children and young people. 8 There may also be future knee damage associated with arthroscopic procedures. 9,

10 However, the evidence base is limited in its quality and scope. Trials of meniscal surgery in patients with osteoarthritis showed high rates of cross-over, with one third of patients in the physical therapy arm undergoing surgery during follow-up. 2, 3 For many applications of knee arthroscopy, no RCT-level evidence is available and, where evidence is available, it may not include all patients of interest. This policy, therefore, specifies that conservative treatment should primarily be used but, when this fails, referral for surgery is an option. In the trial of meniscal surgery compared with conservative treatment in patients without osteoarthritis,1 at earlier time points, outcomes favoured surgery but, by 12 months of conservative treatment, outcomes were equivalent. 1 Therefore, to allow sufficient time for benefits of conservative treatment to be gained, and to allow for any potential natural healing of joint derangements, a minimum 12 months restriction has been selected for which conservative treatment should be attempted before any referral. In this trial, cross-over from the conservative group to surgery over 12 months was low (7%). However, in other trials cross-over has been higher (around 30%)2, 3 suggesting that some patients will require more urgent surgery. There may be some cases where symptoms re-occur on conservative management and these patients may benefit from surgery. 11 Therefore, this policy allows for patients with mechanical locking or worsening symptoms to be referred before the 12 month period of conservative management. Restricted Procedures For some interventions, the evidence identifies a lack of effect or there is insufficient evidence to warrant their use. There is currently no NICE guidance on the use of many procedures but, for the procedures that have been assessed, those not recommended by NICE will not be funded unless part of a research study and prior approval for ‘Excess Treatment Costs’ has been obtained. Further details on application for ‘Excess Treatment costs’ are available on http://www.camstrad.nhs.uk/. There is evidence that lavage does not improve patient outcome compared to sham12-16 and NICE does not recommend lavage. 13 NICE recommends knee meniscus replacement with biodegradable scaffold only with special arrangements for clinical governance, consent and audit or research (based on one cases series). 17 NICE currently recommends that mosaicplasty should

http://www.camstrad.nhs.uk/

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not be used without special arrangements for consent and audit or research. 18 NICE does not currently recommend autologous chondrocyte implantation for the treatment of articular cartilage defects of the knee joint except in the context of on-going or new clinical studies. 19. NICE recommends that arthroscopic trochleoplasty for patellar instability should only be used with special arrangements for clinical governance, consent and audit or research. 20 There is some evidence that debridement is ineffective 12, 14, 15 but NICE recommends that debridement may be appropriate in cases where there is mechanical locking. 12 Restricted use of MRI MRI is a good diagnostic tool21, but may be inaccurate when used by less experienced staff 22 and

its use is, therefore, restricted to secondary care or community MSK providers for this indication.

Numbers of people affected:

In Cambridgeshire and Peterborough, the estimated 2013/14 rate (and cost) of procedures

associated with knee arthroscopy is 1,237 (£2,552,637) per year, equating to approximately 0.12%

of the local population.

References:

1. Sihvonen R, Paavola M, Malmivaara A, Itälä A, Joukainen A, Nurmi H, Kalske J, Järvinen TLN for the Finnish Degenerative Meniscal Lesion Study (FIDELITY) Group. Arthroscopic Partial Meniscectomy versus Sham Surgery for a Degenerative Meniscal Tear. N Engl J Med 2013;369:2515-24. 2. Katz J N, Brophy R H, Chaisson C E, de Chaves L P T, Cole B J, Dahm D L, Donnell-Fink L A, Guermazi A, Haas A K, Jones M H, Levy B A, Mandl L A, Martin S D, Marx R G, Miniaci A, Matava M J, Palmisano J, Reinke E K, Richardson B E, Rome B N, Safran-Norton C E, Skoniecki D J, Solomon D H, Smith M V, Spindler K P, Stuart M J, Wright J, Wright R W, Losina E. Surgery versus Physical Therapy for a Meniscal Tear and Osteoarthritis. The New England Journal of Medicine 2013; 368(18): 1675-84. 3. Herrlin S V, Wange P O, Lapidus G, Hallander M, Werner S, Weidenhielm L. Is arthroscopic surgery beneficial in treating non-traumatic, degenerative medial meniscal tears? A five year follow-up. Knee Surg Sports Traumatol Arthrosc (2013) 21:358–364. 4. Hing C B, Smith T O, Donell S, Song F. Surgical versus non-surgical interventions for treating patellar dislocation. The Cochrane database of systematic reviews 2011. 5. Linko E, Harilainen A, Malmivaara A, Seitsalo S. Surgical versus conservative interventions for

anterior cruciate ligament ruptures in adults. The Cochrane database of systematic reviews 2005.

6. Kettunen J A, Harilainen A, Sandelin J, Schlenzka D, Hietaniemi K, Seitsalo S, Malmivaara A and

Kujala U M Knee arthroscopy and exercise versus exercise only for chronic patellofemoral pain

syndrome: a randomized controlled trial BMC Medicine 2007;5:38.

7 Jameson S S, Dowen D, James P, Serrano-Pedraza I, Reed M R, Deehan D J. The burden of arthroscopy of the knee: a contemporary analysis of data from the English NHS. J Bone Joint Surg Br. 2011 Oct;93(10):1327-33. 8. Ashraf A, Luo T D, Christophersen C, Hunter L R, Dahm D L, McIntosh A L. Acute and subacute complications of pediatric and adolescent knee arthroscopy. Arthroscopy. 2014 Jun;30(6):710-4. 9. Petty C A, and Lubowitz J H. Does Arthroscopic Partial Meniscectomy Result in Knee Osteoarthritis? A Systematic Review With a Minimum of 8 Years’ Follow-up. Arthroscopy 2011; 27(3):419-424. 10. Piedade S R, Alban Pinaroli A, Servien E, Neyret P. Is previous knee arthroscopy related to worse results in primary total knee arthroplasty? Knee Surg Sports Traumatol Arthrosc 2009; 17:328–333 11. Price A, Beard D. Arthroscopy for degenerate meniscal tears of the knee. BMJ 2014;348:g2382. 12. NICE clinical guideline 177. Osteoarthritis: Care and management in adults. 2014.

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13. NICE interventional procedure guidance 230. Arthroscopic knee washout, with or without debridement, for the treatment of osteoarthritis. 2007. 14. Laupattarakasem W, Laopaiboon M, Laupattarakasem P, Sumananont C. Arthroscopic debridement for knee osteoarthritis. The Cochrane database of systematic reviews 2008. 15. Health Quality Ontario. Arthroscopic lavage and debridement for osteoarthritis of the knee: an evidence-based analysis. Ontario health technology assessment series 2005;5(12):1-37. 16. Reichenbach S, Rutjes A W S, Nüesch E, Trelle S, Jüni P. Joint lavage for osteoarthritis of the knee. The Cochrane database of systematic reviews 2010. 17. NICE interventional procedure guidance 430. Partial replacement of the meniscus of the knee using a biodegradable scaffold. 2012. 18. NICE interventional procedure guidance 162. Mosaicplasty for knee cartilage defects. 2006. 19. NICE technology appraisal 89. The use of autologous chondrocyte implantation for the treatment of cartilage defects in knee joints. 2005. 20. NICE interventional procedure guidance 474. Arthroscopic trochleoplasty for patellar instability. 2014. 21. Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. British medical bulletin 2007;84:5-23. 22. Bryan S, Weatherburn G, Bungay H, Hatrick C, Salas C, Parry D, et al. The cost-effectiveness

of magnetic resonance imaging for investigation of the knee joint. Health Technol Assess

2001;5(27):1-95.

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Trigger Finger Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Referral criteria – patients should meet the following criteria.


Moderate symptoms at presentation: a) triggering with difficulty actively extending

finger/need for passive finger extension OR b) loss of complete active flexion

AND Failure to respond to conservative treatment (at least two corticosteroid injections)

OR Severe symptoms (fixed contracture) that cannot be corrected with any other method

OR Corticosteroid treatment is not suitable


OR



…………………………………………………………………………………………………………………………………………………………

…………………………

Definition: Trigger finger (stenosing tenosynovitis) is an acquired condition in which the sheath for the flexor tendon of a finger or the thumb thickens and narrows. This causes the flexor tendon to not glide freely through it, leading to pain, intermittent snapping (“triggering”) or actual locking (in flexion or extension) of the affected digit (finger). Policy: The CCG will ONLY fund surgery for trigger finger according to the following criteria:

The patient has moderate symptoms as defined below which have not improved following conservative treatment (at least one corticosteroid injection). OR

The patient has severe symptoms as defined below that cannot be corrected with any other method. OR

The patient for whom corticosteroid treatment is not suitable.

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Classification for Severity of Trigger Finger1: Mild (pre-triggering): History of pain and catching or “click”. And/or tender A1 pulley (tendon);

but fully mobile finger. Moderate: Triggering with difficulty actively extending finger or need for passive finger

extension. And/or loss of complete active flexion. Severe: Fixed contracture. Note Patients who smoke should have attempted to stop smoking 8 to12 weeks before the operation to reduce the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. 2,3

Rationale and evidence:

Spontaneous recovery has been reported in up to 29% of cases.4 Steroid injections are advised before surgery due to ease of use within the outpatient setting and low morbidity rate or complications.5 Initial treatment of trigger finger is conservative. Steroid injections are efficacious and should be attempted before surgical intervention. 6,7 Trigger finger cure rate has been shown in patients who were treated with corticosteroid injections (57%) and this improved with two injections (86%) whilst remission was achieved in all cases for surgical methods at 6 months. 8


The overall lifetime incidence of trigger finger is 2 in 100. 4 It occurs in childhood and adulthood

(most frequently in the fifth to sixth decades) and is more common in women. 5 Diabetes,

rheumatoid arthritis, thyroid disease, kidney disease and other rarer disorders are risk factors for

trigger finger.

References:

1. British Society for Surgery of the Hand (2010) BSSH Evidence for Surgical Treatment (BEST): Trigger Finger (Stenosing Tenosynovitis) [Online] Available from: http://www.bssh.ac.uk/education/guidelines/trigger.pdf 2. C Furlong. Preoperative Smoking Cessation: A Model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A report by London Health Observatory. September 2005.

3. S Hajioff, M Bhatti. Pre-operative smoking cessation therapy in NCL. A case of short-term gain for long-term gain?

4. Schofield C B, Citron N D. (1993). The natural history of adult trigger thumb. J Hand Surg [Br]. 1993 Apr;18(2):247-8.

5. Wolfe S W. Tenosynovitis, 2137-2158, Chapter 60. Green’s Operative Hand Surgery Ed’s Green DP, Hotchkiss RN, Pederson W C, Wolfe S W . Elsevier, Churchill Livingstone, 2005.

6. Sheryl B, Fleisch, B S, et al. (2007). Corticosteroid Injections in the Treatment of Trigger Finger: A Level I and II Systematic Review. J Am Acad Orthop Surg, Vol 15, No 3, March 2007, 166-171.

7. Kerrigan C L, Stanwix M G. (2009). Using evidence to minimize the cost of trigger finger care. J Hand Surg Am. 2009 Jul-Aug;34(6):997-1005.

8. Sato E S, Gomes Dos Santos J B, et al. (2011) Treatment of trigger finger: randomized clinical trial comparing the methods of corticosteroid injection, percutaneous release and open surgery. Rheumatology (Oxford). 2012 Jan;51(1):93-9.

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Spinal Surgery Checklist as per Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and Hertfordshire Priorities Forum Definition: 1. Chronic low back pain is defined as pain in the lumbar region that has lasted for more than 6 weeks1. Chronic pain may be due to specific lumbar pathology such as, but not limited to, spinal instability, spondylosis/spondylolisthesis, spinal stenosis, discogenic back pain, disc herniation or prolapse, or due to non-specific chronic back pain for which a diagnosis is not possible1-7.

2. This policy refers to chronic back pain and does not include acute back pain conditions such as fracture, dislocation, complications of tumour or infection and/or nerve root or spinal compression responsible for progressive neurological deficit.

3. This policy does not cover some of the causes of chronic back pain such as osteoporosis and related compression fractures, lumbar spine arthritis, infection, tumour, sagittal imbalance and spinal deformity.

4. GPs should refer to secondary care directly for “red flag patients”, ie suspected cancer or cauda equina compression 8, 9, 14. Policy: Conservative Management Patients presenting mainly with problems of lumbar spondylosis without compromise to the nerve root should be treated conservatively. Access to physiotherapy advice and pain relief should be available to shorten absence from work and usual activities. Surgical Management Patients with lumbar disc conditions including ‘acute on chronic’ or chronic low back pain (duration of over six weeks1, 7), will only receive non-acute spinal surgery under the following circumstances:

1. Surgical discectomy (standard or microdiscectomy) in selected patients with sciatica secondary to disc prolapse where conservative management has failed for at least 12 weeks3; and

if radicular pain has not responded to non-invasive treatment after 12 weeks; and

the patient has been referred to Tier II musculoskeletal assessment service for assessment for spinal surgery or other non-invasive intervention; and

the patient has lumbar radiculopathy with corresponding intervertebral disc prolapse on magnetic resonance imaging (MRI).

2. Severe spinal stenosis with symptoms of neurogenic claudication and the MRI shows significant canal stenosis (IPG 365) 3,10.

3. Spinal fusion may be considered for non-specific back pain if severe pain continues despite two years of active rehabilitation, cognitive intervention combined with exercises where available and the patient has been assessed by a specialist using appropriate scans (CG88)

11, 14. Low Priority

1. The use of spinal surgery for the treatment of chronic, non-specific low back pain not covered by this policy is a low priority on the grounds of limited evidence of clinical effectiveness. Referral and treatment should only be considered under exceptional circumstances14.

2. Endoscopic laser spinal surgery (discectomy, foraminoplasty or endoscopic division of epidural adhesions) for chronic back and leg pain, caused by disc prolapse or adhesions formed around the spinal nerve roots is of unproven benefit and should not be performed (IPG031, IPG061, IPG303, IPG333) 16-19.

3. Injections of therapeutic substances for cases with chronic pain is a low priority on the grounds of limited evidence of clinical effectiveness23.

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Lumbar epidural, caudal, interlaminar, transforaminal, intraarticular facet and sacroiliac joint steroid injections; lumbar medial branch blocks and lumbar intradiscal injections with methylene blue are NOT recommended for the treatment of following:

o Low back pain with sciatica or radiculopathy. o Low back pain without sciatica or radiculopathy. o Spinal Stenosis. o Failed back surgery syndrome. o Disc prolapse or discogenic back pain. o Confirmed and presumed facet joint pain. o Facet joint osteoarthritis. o Non radicular back pain. o Sacroiliac joint pain.

Cervical spinal epidural injections, facet joint injections and medial branch blocks are NOT recommended for the following:

o Neck pain with disc herniation and radiculitis. o Neck pain without disc herniation. o Disc compression and radiculitis. o Confirmed facet joint pain.

Spinal injections are NOT recommended for non-specific low back pain1. (NICE CG88.)

4. Patients with acute radiculopathy may benefit from a nerve root block. Patients need careful selection.

5. The following treatments should not be offered for the early management of persistent non-specific low back pain (NICE CG88) 14:

SSRIs (Selective Serotonin Reuptake Inhibitors) for treating pain.

Laser therapy.

Interferential therapy.

Therapeutic Ultrasound.

TENS (Transcutaneous Electrical Nerve Simulation).

Lumbar supports.

Traction.

Intradiscal Electrothermal Therapy (IDET), Percutaneous Intradiscal Radiofrequency Thermo coagulation (PIRFT) and radiofrequency facet joint denervation (IPG319) 20.

Rationale: Conservative treatment includes analgesia, non-steroidal anti-inflammatory drugs and exercises. ‘Watchful waiting’ is recommended after referral to the intermediate tier because 70% of acute disc prolapse cases will settle spontaneously with conservative treatment. The assessment should be in line with national care pathways (www.18week.nhs.uk) and as defined in local Practice Based Commissioners triage pathways. Psychological distress is a predictor of poor outcome at 12 months and 7 years following surgery21. There is no clear evidence that surgical stabilisation is more effective than intensive rehabilitation in relieving patients of symptoms of low back pain2-7. Additionally, there is cost utility evidence showing that surgical stabilisation of the spine may not be a cost effective use of scarce healthcare resources5. Surgery is controversial, but some advocate spinal fusion in a very few selected patients with degenerative disc disease. Fusion with metalwork and bone graft may be performed for spondylolisthesis, but the outcome is variable, depending on the type and degree of slip. Surgery can provide effective clinical relief in the above circumstances3. The Washington HTA provides the most recent evidence review available on spinal injections. No benefit was found for the spinal injections for most of the clinical indications and those with positive outcomes had limitations with conflicting evidence, strength of evidence, quantity or consistency of data.

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The UK cost effective data included in the HTA suggests cost effectiveness ratios for a single epidural steroid injection are too high to be considered cost effective by UK conventions. Therefore, clinicians and commissioners should take into account this caveat before decision making. Current evidence on the safety and efficacy of percutaneous intradiscal laser ablation in the lumbar spine is adequate to support the use of this procedure provided that normal arrangements are in place for clinical governance, consent and audit (IPG357) 15. There is insufficient current evidence of effectiveness for:

Newer forms of thermal and laser spinal procedures3, 7. NICE guidance IPG31, 61, 303, and 33316-19, states that “current evidence on the safety and efficacy of such treatments does not appear adequate to support the use of the procedures.” Referrals for this treatment will not be supported except in exceptional circumstances.

Surgery for degenerative lumbar spondylosis/degenerative disc disease/spinal stenosis2-7 except in cases where MRI shows significant spinal canal stenosis and neurogenic claudication. Patients need careful selection.

Evidence on safety and efficacy of lateral (including extreme, extra and direct lateral) interbody fusion in the lumbar spine was found inadequate by NICE, hence should not be performed (IPG321) 24.

Further good quality random controlled trials are needed to provide evidence on short and long term pain relief with lumbar facet joint injection therapy, medial branch blocks and medial branch neurotomy25, anaesthetic blocks of facet joints26 and radiofrequency denervation of low back pain26.

Smoking Patients who smoke should have stopped smoking 8 to 12 weeks before the operation to reduce the risk of surgery and the risk of post-surgery complications. Patients should be routinely offered referral to smoking cessation services to reduce these surgical risks. Evidence: NICE Clinical guidelines 1, 14 and interventional procedure guidelines8, 10-20, 24 have been reviewed and adopted. This policy also derives its evidence from a 2005 Cochrane Collaboration review2, updated by the systematic review (Van Tulder 20053). Also incorporating MRC Stabilisation Trial4, companion cost utility analysis4, systematic reviews 6, 25-27, randomised trials5, Washington Health Technology Assessment23, epidemiological studies22, 28, burden of disease study30 and European Guidelines7, 29. Numbers of people affected: Epidemiological Background Low back pain is a common problem affecting both genders and most ages for which approximately one in four adults seeks care in a six-month period22. Research indicates that most recent onset lower back pain episodes settle, but only about one in three resolves completely over a twelve-month period22. Low back pain is very common in working-age adults, especially ages 40 to 60 years, with different levels of severity and represents a considerable burden to patients, families, society and the economy 8, 14. Estimates of the prevalence of low back pain vary considerably between studies with estimates of point prevalence up to 33%, one-year prevalence of 65% and lifetime prevalence of 84%28. A UK survey reported in 1998 that 40% of adults had suffered from lower back pain lasting longer than one day in the previous twelve months29. In 2002, it was estimated that there are 2.6 million people in the UK seeking advice about back pain from their GP each year1. Cost of Back Pain In 1998 the health care costs due to back pain were £1,632M, of which £565M was the cost of non-NHS health care costs. These are the most recent costs available for the UK. It is difficult to

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estimate the current economic burden due to change in economic climate and inflation. The UK retail price index, however, increased by 28.8% in the ten years to July 2008 indicating that current direct health care costs are likely to be considerably higher than the published figures. Additionally, indirect costs of back pain, due to lost production are much greater. The 1998 estimate was either £3,440M, or £9,090M depending on the approach used for costing1, 30. References: 1. Savigny P, Kuntze S, Watson P, et al. Low Back Pain: early management of persistent non-specific low back pain. London: National Collaborating Centre for Primary Care and Royal College of General Practitioners.

2. Van Tulder M, Koes B, Seitsalo S, Malmivaara A. Outcome of invasive treatment modalities on back pain and sciatica: an evidence-based review. http://www.springerlink.com/content/718525118748783t/fulltext.pdf.

3. Gibson JNA, Waddell G. Surgery for degenerative lumbar spondylosis. Cochrane Database of Systematic Reviews 2005, Issue 4.

4. Fairbank J, Frost H, Wilson-MacDonald J et al. Randomised controlled trial to compare surgical stabilisation of the lumbar spine with an intensive rehabilitation programme for patients with chronic low back pain: the MRC spine stabilisation trial. BMJ. 2005 May 28;330(7502):1233. Epub 2005 May 23.

5. Rivero-Arias O, Campbell H, Gray A et al. Surgical stabilisation of the spine compared with a programme of intensive rehabilitation for the management of patients with chronic low back pain: cost utility analysis based on a randomised controlled trial. BMJ. 2005 May 28; 330(7502): 1239.

6. Jacobs WCH, Vreeling A and De Kleuver M. Fusion for low-grade adult isthmic spondylolisthesis: a systematic review of the literature. Eur Spine J. 2006; 15: 391-402.\ 7. Airaksinen O, Brox JL, Cedraschi C, Hildebrandt J, Klaber-Moffett J, Kovacs F, Mannion AF, Reis S, Staal JB, Ursin H and Zanoli G. European Guidelines for the Management of Chronic Non-Specific Low Back Pain. November 2004, Amended June 2005. On behalf of the COST B13 Working Group on Guidelines for Chronic Low Back Pain. http://www.backpaineurope.org/

8. National Institute for Health and Clinical Excellence (NICE) Low back pain: Draft scope for consultation February 2007. http://guidance.nice.org.uk/nicemedia/live/11645/34378/34378.pdf

9. Gamlin G, Taylor A and Fechter K. GP guidance for the management of musculoskeletal conditions developed on behalf of Huntscom.

10. National Institute for Health and Clinical Excellence. Interventional Procedures Guidance (IPG) 365 Interspinous distraction procedures for lumbar spinal stenosis causing neurogenic claudication. November 2010.

11. National Institute for Health and Clinical Excellence. Interventional Procedure overview of transaxial interbody lumbosacral fusion Interventional procedures programme 843. November 2010.

12. National Institute for Health and Clinical Excellence. IPG366 Non-rigid stabilisation techniques for the treatment of low back pain. November 2010.

13. National Institute for Health and Clinical Excellence. IPG306 Prosthetic intervertebral disc replacement in the lumbar spine. (2009). www.nice.org.uk/guidance/IPG306

14. National Institute for Health and Clinical Excellence. Clinical Guideline (CG) 88 (2009) Early management of persistent non-specific low back pain. www.nice.org.uk/guidance/CG88

15. National Institute for Clinical Excellence. IPG0357 Percutaneous intradiscal laser ablation in the lumbar spine. September 2010. http://www.nice.org.uk/nicemedia/live/11057/50863/50863.pdf

16. National Institute for Clinical Excellence. IPG031 Endoscopic laser foraminoplasty, guidance. December 2003. http://www.nice.org.uk/nicemedia/live/11028/30622/30622.pdf

17. National Institute for Clinical Excellence. IPG061 Percutaneous endoscopic laser thoracic discectomy, guidance. May 2004. http://www.nice.org.uk/nicemedia/live/11106/31066/31066.pdf

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18. National Institute for Clinical Excellence. IPG303 Percutaneous endoscopic laser cervical discectomy. June 2009. http://www.nice.org.uk/nicemedia/live/12074/44657/44657.pdf

19. National Institute for Clinical Excellence. IPG333 Therapeutic endoscopic division of epidural adhesions. February 2010. http://www.nice.org.uk/nicemedia/live/11066/47515/47515.pdf

20. National Institute for Health and Clinical Excellence. IPG319 Percutaneous intradiscal electrothermal therapy for low back pain. www.nice.org.uk/guidance/IPG319.

21. den Boer JJ, Oostendorp RA, Beems T et al: A systematic review of bio-physical risk factors for an unfavourable outcome after lumbar disc surgery, European Spine Journal 15;527-536, 2006.

22. Kent PM and Keating JL. The epidemiology of low back pain in primary care. Chiropractic & Osteopathy. 2005; 13:13-19.

23. Robin H,Annie R, Erika E et al. Spinal Injection. WA Health Technology Assessment . Spectrum Research .November 2010. Available from http://www.hta.hca.wa.gov/documents/spinal_injection_draft_report.pdf Accessed 2 December 2010. 24. National Institute for Clinical Excellence. IPG321 Lateral (including extreme, extra and direct lateral) interbody fusion in the lumbar spine. November 2009. http://www.nice.org.uk/nicemedia/live/12138/46410/46410.pdf

25. Boswell MV, Colson JD, Sehgal N, Dunbar EE and Epter R. A systematic review of therapeutic facet joint interventions in chronic spinal pain. Pain Physician 2007; 10: 229-253.

26. Sehgal N, Dunbar EE, Shah EV and Colson J. Systematic review of diagnostic utility of facet (zygapophisial) joint injections in chronic spinal pain: an update. Pain Physician 2007; 10:213-228.

27. Niemisto L, Kalso E, Malmivaara A, Seitsalo S and Hurri H. Radiofrequency denervation for neck and back pain. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No. CD004058.

28. Walker BF. The prevalence of low back pain: a systematic review of the literature from 1966 to 1998. J Spinal Disord. 2000; 13 (3):205-217.

29. Airaksinen O, Brox JI, Cedraschi C, Hildebrandt J et al. Chapter 4. European guidelines for the management of chronic nonspecific low back pain. Eur Spine J. 2006; 15 (Suppl 2):S192-S300.

30. Maniadakis N, Gray A. The economic burden of back pain in the UK. 2000; 84 (1):95-103.

31. Blacks Medical Dictionary, 42nd edition, published 2010.

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Management of shoulder pain (including referral for surgical assessment) as per

Cambridgeshire and Peterborough Clinical Commissioning Group and Bedfordshire and

Hertfordshire Priorities Forum

This policy covers the treatment of shoulder pain, including conservative management and, where

necessary, referral to a specialist for surgical assessment.

For patients not meeting the policy criteria, clinicians can apply for funding to the Exceptional Case Panel

Patients with a traumatic injury or dislocation may be referred to Trauma and

Orthopaedics.

Patients with non-traumatic shoulder pain should be given conservative management:

Self-care advice on modifying activities, use of NSAIDs and home exercises.

If these are not effective, patients should be referred for physiotherapy.

Steroid injections will only be funded for patients whose pain is not controlled by NSAIDs or in whom the use of NSAIDs are contraindicated and other conservative management has failed. NB: in cases where injections are necessary to enable a patient to undergo physiotherapy, these may be used at the time of the first course of physiotherapy.

US Scans: An USS scan will be funded where a first course of physiotherapy (≥3 months) is

judged to be ineffective and a rotator cuff tear is suspected. If there is a known trauma and

significant functional limitation this referral can be done before physiotherapy. Referral for

MRA scans should only be made by secondary care consultants or specialists working in CCG

commissioned musculoskeletal (MSK) services if a labral tear is suspected. Where patients are

referred for a surgical assessment, these scans should be made available to the receiving

institution.

Surgery: Where an MRA scan/ultrasound has demonstrated evidence of a full thickness rotator

cuff tear or significant superior labral anterior-posterior tear (detachment of labrum), shoulder

surgery will be funded.

For other conditions, before shoulder surgery will be funded, patients should have undergone

further conservative management of:

3 months: partial thickness tears or minor superior labral anterior-posterior tears (fraying).

6 months: adhesive capsulitis, impingement syndrome, non-traumatic instability, calcific tendonitis, biceps tendonitis or acromioclavicular or glenohumeral arthritis*.

Shoulder arthroscopy will not be funded as a diagnostic tool.

* Where there is clear evidence of severe progressive osteoarthritis, physiotherapists may

refer patients before 6 months.

NOTE:

Patients who smoke should be advised to attempt to stop smoking and referred to smoking

cessation services.

Patients who are overweight or obese should be offered referral to the appropriate weight

management service.

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Shoulder pathway

Shoulder Surgery:

An RCT of rotator cuff tears suggest that, for patients with traumatic or atraumatic full

thickness rotator cuff tears, physiotherapy may be effective in some cases, but in others,

surgery may be needed1, 2. For partial thickness rotator cuff tears, physiotherapy is likely to be

effective in many cases3 and surgery may be unnecessary and, for patients with impingement

syndrome, physiotherapy is likely to be effective for most, with surgery needed in fewer cases4-6.

For calcific tendonitis no RCTs compared the use of rest, exercise or physiotherapy with surgical

interventions. One RCT compared ultrasound-guided barbotage (needling and washout) with

corticosteroid injections and suggested that surgery gives a greater improvement in pain and

function7. Surgery is unlikely to be necessary in most cases, but may be helpful in sever

refractory calcific tendonitis. Similarly, for biceps tendonitis, there were no RCTs comparing the

use of conservative treatment with surgical interventions, although case series suggest that

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surgery may be beneficial8-10. Surgery should be reserved for patients who are refractory to

conservative management, but where there are superior labral anterior-posterior (SLAP) tears,

surgery may be necessary11.

For adhesive capsulitis, one small RCT compared arthroscopic capsular release with exercise therapy and suggested that surgery may be no more effective12. There were no RCTs comparing it with other interventions. Surgery should be reserved for patients who are refractory to conservative management. For acromioclavicular and glenohumeral osteoarthritis, there were no RCTs comparing the use of conservative with surgical interventions. NICE recommends advice to exercise as a core treatment, including local muscle strengthening and general aerobic fitness13 and the use of surgery may not be necessary in most cases.

For glenohumeral joint dislocation/instability, following traumatic dislocations, RCTs suggest

that surgery may be necessary and a surgical opinion is needed14, 15. For multidirectional (non-

traumatic) dislocations, conservative therapy may be effective16, 17 and surgery may not be

necessary. For acromioclavicular separation/instability trials suggest that, for many patients

with ACL separation/dislocation, conservative treatment is sufficient18. For patients with grade

IV or greater dislocation, surgery is likely to be necessary. For patients with grade I-II dislocation

surgery is unlikely to be necessary and, for grade III dislocation, surgery may not always be

necessary19, 20.

Manipulation under anaesthetic: There were no RCTs of manipulation under anaesthetic compared with conservative treatments. It is likely to benefit some patients21, 22, but should be used after other conservative interventions.

Diagnostic tests: For many conditions associated with shoulder pain may be difficult to

distinguish between different pathologies with physical examination23-25 and an imaging test (MRI,

MRA or ultrasound) may be necessary26.

Steroid injections: RCTs and comparative studies suggest that steroid injections may be useful

for short-term pain relief for rotator cuff disease27-29 calcific tendonitis30 and adhesive capsulitis31,

and NICE recommend corticosteroid injections for patients with moderate to severe osteoarthritis

pain13. However, there is inadequate evidence to suggest that they improve function.

Numbers of people affected

In Cambridgeshire and Peterborough, the estimated 2014/15 rate of procedures associated with

surgery for rotator cuff tears/impingement and adhesive capsulitus was 418 per year (costing £1.8

million), equating to approximately 0.04% of the local population.

Relevant OPCS codes

O29.1 Subacromial decompression.

O27.2 Repair of capsule and anterior and posterior labrum for stabilisation of glenohumeral

joint.

O27.3 Repair of capsule and anterior labrum for stabilisation of glenohumeral joint.

O27.4 Repair of capsule and posterior labrum for stabilisation of glenohumeral joint.

T79.1 Plastic repair of rotator cuff of shoulder NEC.

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T79.3 Revisional repair of rotator cuff NEC.

T79.4 Plastic repair of multiple tears of rotator cuff of shoulder.

T79.5 Revisional repair of multiple tears of rotator cuff of shoulder.

W78.1 Release of contracture of shoulder joint.

W84.7 Endoscopic repair of superior labrum anterior to posterior tear.

Glossary

Acromioclavicular

separation:

The disruption of the acromioclavicular joint where the collarbone

(clavicle) meets the highest point of the shoulder blade (acromion)

Adhesive capsulitis: Known as ‘frozen shoulder’. The flexible tissue that surrounds the

shoulder joint, becomes inflamed and thickened leading to pain

and stiffness.

Arthroscopy: Key-hole surgery using an arthroscope (light source and video

camera).

Biceps tendonitis: Inflammation in the main tendon that attaches the top of the

biceps muscle to the shoulder

Calcific tendonitis

(Shoulder):

Build-up of calcium deposits in the rotator cuff tendons

Debridement: Removal of dead, damaged, or infected tissue.

Extracorporeal shock

wave therapy:

procedure where shock waves (low energy sound waves) are passed

through the skin

Glenohumeral

dislocation:

Ball joint of upper arm has popped out of the shoulder socket.

Impingement syndrome: Friction between tendon in the shoulder and the bone under which

it passes, causing pain

NSAIDs: Non-steroidal anti-inflammatory drugs. Medication used to relieve

pain and inflammation and reduce temperature.

Shoulder instability: Instability of the shoulder joints due to acromioclavicular

separation or glenohumeral dislocation

Osteoarthritis: Degenerative joint disease that occurs when the cartilage that

covers the tops of bones degenerates or wears down, causing

swelling, pain and sometimes ‘bone spurs’ (additional bone growth

where bones rub together)

Rotator cuff: Group of four muscles that are positioned around the shoulder

joint. The tendons of these muscles join together to form the

rotator cuff tendon

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References

1. Moosmayer S, Lund G, Seljom U, et al. Comparison between surgery and

physiotherapy in the treatment of small and medium-sized tears of the rotator cuff: A

randomised controlled study of 103 patients with one-year follow-up. The Journal of bone and

joint surgery. British volume. Jan 2010;92(1):83-91.

2. Moosmayer S, Lund G, Seljom U S, et al. Tendon repair compared with physiotherapy in the

treatment of rotator cuff tears: a randomized controlled study in 103 cases with a five-year

follow-up. The Journal of bone and joint surgery. American volume. Sep 17 2014;96(18):1504-

1514.

3. Kukkonen J, Joukainen A, Lehtinen J, et al. Treatment of non-traumatic rotator cuff tears: A

randomised controlled trial with one-year clinical results. The bone & joint journal. Jan

2014;96-B(1):75-81.

4. Rahme H, Solem-Bertoft E, Westerberg C E, Lundberg E, Sorensen S, Hilding S. The

subacromial impingement syndrome. A study of results of treatment with special emphasis on

predictive factors and pain-generating mechanisms. Scandinavian journal of rehabilitation

medicine. Dec 1998;30(4):253-262.

5. Haahr J P, Ostergaard S, Dalsgaard J, et al. Exercises versus arthroscopic decompression in

patients with subacromial impingement: a randomised, controlled study in 90 cases with a one

year follow up. Annals of the rheumatic diseases. May 2005;64(5):760-764.

6. Brox J I, Staff P H, Ljunggren A E, Brevik J I. Arthroscopic surgery compared with supervised

exercises in patients with rotator cuff disease (stage II impingement syndrome). BMJ. Oct 9

1993;307(6909):899-903.

7. de Witte P B, Selten J W, Navas A, et al. Calcific tendinitis of the rotator cuff: a randomized

controlled trial of ultrasound-guided needling and lavage versus subacromial corticosteroids.

The American journal of sports medicine. Jul 2013;41(7):1665-1673.

8. Gupta A K, Chalmers P N, Klosterman E L, et al. Subpectoral biceps tenodesis for bicipital

tendonitis with SLAP tear. Orthopedics. Jan 2015;38(1):e48-53.

9. Taylor S A, Fabricant P D, Baret N J, et al. Midterm clinical outcomes for arthroscopic

subdeltoid transfer of the long head of the biceps tendon to the conjoint tendon. Arthroscopy

: the journal of arthroscopic & related surgery : official publication of the Arthroscopy

Association of North America and the International Arthroscopy Association. Dec

2014;30(12):1574-1581.

10. Kelly A M, Drakos M C, Fealy S, Taylor S A, O'Brien S J. Arthroscopic release of the long head

of the biceps tendon: functional outcome and clinical results. The American journal of sports

medicine. Feb 2005;33(2):208-213.

11. Tokish JM, McBratney CM, Solomon DJ, Leclere L, Dewing CB, Provencher MT. Arthroscopic

repair of circumferential lesions of the glenoid labrum: surgical technique. The Journal of

bone and joint surgery. American volume. Sep 2010;92 Suppl 1 Pt 2:130-144.

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References cont'd

12. Smitherman J A, Struk A M, Cricchio M, et al. Arthroscopy and manipulation versus home therapy

program in treatment of adhesive capsulitis of the shoulder: a prospective randomized study. Journal

of surgical orthopaedic advances. Spring 2015;24(1):69-74.

13. National Institute for Health and Care Excellence. NICE clinical guidance 177. Osteoarthritis: care and

management in adults. 2014.

14. Handoll H H, Almaiyah M A, Rangan A. Surgical versus non-surgical treatment for acute anterior

shoulder dislocation. The Cochrane database of systematic reviews. 2004(1):CD00432\a5.

15. Jakobsen B W, Johannsen H V, Suder P, Sojbjerg J O. Primary repair versus conservative treatment of

first-time traumatic anterior dislocation of the shoulder: a randomized study with 10-year follow-up.

Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy

Association of North America and the International Arthroscopy Association. Feb 2007;23(2):118-123.

16. Warby S A, Pizzari T, Ford J J, Hahne A J, Watson L. The effect of exercise-based management for

multidirectional instability of the glenohumeral joint: a systematic review. Journal of shoulder and

elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. Jan 2014;23(1):128-142.

17. Milewski M D, Nissen C W. Pediatric and adolescent shoulder instability. Clinics in sports medicine.

Oct 2013;32(4):761-779.

18. Tamaoki M J, Belloti J C, Lenza M, Matsumoto M H, Gomes Dos Santos J B, Faloppa F. Surgical versus

conservative interventions for treating acromioclavicular dislocation of the shoulder in adults. The

Cochrane database of systematic reviews. 2010(8):CD007429.

19. Ceccarelli E, Bondi R, Alviti F, Garofalo R, Miulli F, Padua R. Treatment of acute grade III

acromioclavicular dislocation: a lack of evidence. Journal of orthopaedics and traumatology : official

journal of the Italian Society of Orthopaedics and Traumatology. Jun 2008;9(2):105-108.

20. Smith T O, Chester R, Pearse E O, Hing C B. Operative versus non-operative management following

Rockwood grade III acromioclavicular separation: a meta-analysis of the current evidence base.

Journal of orthopaedics and traumatology : official journal of the Italian Society of Orthopaedics

and Traumatology. Mar 2011;12(1):19-27.

21. Uppal H S, Evans J P, Smith C. Frozen shoulder: A systematic review of therapeutic options. World

journal of orthopedics. Mar 18 2015;6(2):263-268.

22. Grant J A, Schroeder N, Miller B S, Carpenter J E. Comparison of manipulation and arthroscopic

capsular release for adhesive capsulitis: a systematic review. Journal of shoulder and elbow surgery

/ American Shoulder and Elbow Surgeons ... [et al.]. Aug 2013;22(8):1135-1145.

23. Hanchard N C, Lenza M, Handoll H H, Takwoingi Y. Physical tests for shoulder impingements and local

lesions of bursa, tendon or labrum that may accompany impingement. The Cochrane database of

systematic reviews. 2013;4:CD007427.

24. Chen H S, Lin S H, Hsu Y H, Chen S C, Kang J H. A comparison of physical examinations with

musculoskeletal ultrasound in the diagnosis of biceps long head tendinitis. Ultrasound in medicine &

biology. Sep 2011;37(9):1392-1398.

25. Cadogan A, McNair P, Laslett M, Hing W. Shoulder pain in primary care: diagnostic accuracy of

clinical examination tests for non-traumatic acromioclavicular joint pain. BMC musculoskeletal

disorders. 2013;14:156.

26. Roy J S, Braen C, Leblond J, et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography

in the characterisation of rotator cuff disorders: a meta-analysis. British journal of sports medicine.

Feb 11 2015.

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27. Boudreault J, Desmeules F, Roy J S, Dionne C, Fremont P, Macdermid J C. The efficacy of oral non-

steroidal anti-inflammatory drugs for rotator cuff tendinopathy: a systematic review and meta-

analysis. Journal of rehabilitation medicine. Apr 2014;46(4):294-306.

28. Buchbinder R, Green S, Youd J M. Corticosteroid injections for shoulder pain. The Cochrane database

of systematic reviews. 2003(1):CD004016.

29. Gialanella B, Bertolinelli M. Corticosteroids injection in rotator cuff tears in elderly patient: pain

outcome prediction. Geriatrics & gerontology international. Oct 2013;13(4):993-1001.

30. Gaujoux-Viala C, Dougados M, Gossec L. Efficacy and safety of steroid injections for shoulder and

elbow tendonitis: a meta-analysis of randomised controlled trials. Annals of the rheumatic diseases.

Dec 2009;68(12):1843-1849.

31. Maund E, Craig D, Suekarran S, et al. Management of frozen shoulder: a systematic review and

cost-effectiveness analysis. Health Technol Assess. 2012;16(11):1-264.

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This policy covers the management of patients with chronic hip pain. This policy does not cover

indications for referral such as infection, malignancy or acute traumatic event.

Chronic hip pain treatment- as per the Cambridgeshire and Peterborough Clinical Commissioning

Group guidelines and Bedfordshire and Hertfordshire Priorities Forum

It is the responsibility of referring and treating clinicians to ensure compliance with this policy

Surgery

For patients with indication for hip replacement, please see Primary Hip Replacement Surgery Policy.

Hip Resurfacing is a low priority treatment and will not be funded without exceptional case panel approval.

Other arthroscopic or open hip surgery is a low priority treatment and will not be funded without exceptional case panel approval (including femoro-acetabular impingement, non-acute labral, ligamentum teres or abductor tendon tears, greater trochanteric pain syndrome/ trochanteric bursitis and osteoarthritis).

The CCGs will fund open or arthroscopic hip surgery for the treatment of femoro‐acetabular

impingement (FAI) ONLY when patients fulfil all of the following criteria:

Diagnosis of definite femoro‐acetabular impingement defined by appropriate investigations, X‐rays, MRI and CT scans.

An orthopaedic surgeon who specialises in young adult hip surgery has made the diagnosis. This should include discussion of each case with a specialist musculoskeletal radiologist.

Severe symptoms typical of FAI with duration of at least six months where diagnosis of FAI has been made as above.

Failure to respond to all available conservative treatment options including activity modification, pharmacological intervention and specialist physiotherapy.

Compromised function, which requires urgent treatment within a 6‐8 months time frame, or where failure to treat early is likely to significantly compromise surgical options at a future date.

Treatment with more established surgical procedures is not clinically viable.

Hip arthroscopy is supported for the removal of radiologically proven loose bodies within the

hip joint with an associated acute traumatic episode. Arthroscopy is not supported as a

diagnostic tool where there is suspicion of loose bodies.

Hip arthroscopy is supported for the excision of radiological proven labral tears associated with

an acute traumatic episode in the absence of OA or FAI

syndrome.

http://www.cambsphn.nhs.uk/Libraries/Surgical_Threshold_Policies/PRIMARY_HIP_REPLACEMENT_-_FEB_2015_V5.sflb.ashx

http://www.cambsphn.nhs.uk/Libraries/Surgical_Threshold_Policies/PRIMARY_HIP_REPLACEMENT_-_FEB_2015_V5.sflb.ashx

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Injections

Up to 3 corticosteroid injections will be funded for the treatment of hip osteoarthritis.

Corticosteroid injections will be funded for the treatment of hip bursitis (trochanteric or other) as required.

Corticosteroid injections for other hip indications will not be funded without exceptional case panel approval.

Injections of other substances into the hip will not be funded without exceptional case panel approval.

Evidence and rationale

For surgical treatment of hip pain, other than hip replacement for osteoarthritis, only case series studies

have been published (femoro-acetabular impingement syndrome1, 2, 3, 4, labral tears5 greater trochanteric

pain syndrome6, 5, 7, 8, snapping hip syndrome5, 9, ligamentum teres10 and gluteal/abductor tendon

tears11,12) and the effectiveness of arthroscopic or open surgery compared with conservative management

is unclear. For hip osteoarthritis, there are only case series studies of surgeries other than hip

replacement5 and there is evidence of high subsequent rates of conversion to total hip replacement13.

NICE does not recommend hip resurfacing unless the predicted conversion rate to hip replacement is 5%

or less at 10 years14. Data from current trials indicate that conversion rates are much higher than

this15,16.

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Evidence and Rationale cont’d

Corticosteroid hip injections have been shown to relieve pain in patients with hip osteoarthritis

compared with conservative management17, 18, 19 and to aid the resolution of hip bursitis20, but no

evidence of effectiveness was found for other conditions. NICE recommend that hyaluronic acid

injections should not be used for the management of osteoarthritis21.

Numbers of people affected

The prevalence of all causes of hip disease severe enough to require surgery has been estimated at 15.2

per 1,000 people aged 35 to 85 years of age22. It has been estimated, based on radiographic evidence,

that between 10% and 25% of people over the age of 55 years have osteoarthritis of the hip.

Symptomatic hip osteoarthritis has been estimated to affect between 0.7% and 4.4% of adults.

OPCS codes

Hip Replacement See link to Total Hip Replacement Policy.

Hip Joint Injections

W903 Injection of therapeutic substance into joint combined with Z843 Hip joint or Z902 Hip NEC.

X382 Injection of steroid for local action NEC combined with Z843 Hip joint or Z902 Hip NEC.

Hip Resurfacing

W581 Primary resurfacing arthroplasty of joint with Z843.

W582 Revision of resurfacing arthroplasty of joint with Z843.

W327 Conversion to total prosthetic replacement of hip joint using cement.

W382 Conversion to total prosthetic replacement of hip joint not using cement.

W472 Conversion to prosthetic replacement of head of femur not using cement.

W942 Conversion to hybrid prosthetic replacement of hip joint using cemented femoral component.

Other Hip Surgery (including):

W782 Release of contracture of hip joint.

T622 Excision of bursa NEC with Z843.

W844 Endoscopic decompression of joint with Z843.

W889 Unspecified diagnostic endoscopic examination of other joint with Z843.

W918 Other specified other manipulation of joint with Z843.

W919 Unspecified other manipulation of joint with Z843.

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References

1. Bedi, A., Chen, N., Robertson, W. & Kelly, B. T. The Management of Labral Tears and

Femoroacetabular Impingement of the Hip in the Young, Active Patient. Arthrosc. J. Arthrosc. Relat. Surg. 24, 1135–1145 (2008).

2. Clohisy, J. C., St John, L. C. & Schutz, A. L. Surgical Treatment of Femoroacetabular Impingement: A Systematic Review of the Literature. Clin. Orthop. Relat. Res. 468, 555–564 (2010).

3. Collins, J. a., Ward, J. P. & Youm, T. Is Prophylactic Surgery for Femoroacetabular Impingement Indicated?: A Systematic Review. Am. J. Sports Med. 42, 3009–3015 (2014).

4. De SA, D. et al. Extra-Articular Hip Impingement: A Systematic Review Examining Operative Treatment of Psoas, Subspine, Ischiofemoral, and Greater Trochanteric/Pelvic Impingement. Arthrosc. J. Arthrosc. Relat. Surg. 30, 1026–1041 (2014).

5. Stevens, M. S., Legay, D. a, Glazebrook, M. a & Amirault, D. The evidence for hip arthroscopy: grading the current indications. Arthroscopy 26, 1370–83 (2010).

6. Craig, R. a., Gwynne Jones, D. P., Oakley, A. P. & Dunbar, J. D. Iliotibial Band Z-Lengthening for Refractory Trochanteric Bursitis (Greater Trochanteric Pain Syndrome). ANZ J. Surg. 77, 996–998 (2007).

7. Lustenberger, D. P., Ng, V. Y., Best, T. M. & Ellis, T. J. Efficacy of treatment of trochanteric bursitis: a systematic review. Clin. J. Sport Med. 21, 447–453 (2011).

8. Govaert, L. H. M., van der Vis, H. M., Marti, R. K. & Albers, G. H. R. Trochanteric reduction osteotomy as a treatment for refractory trochanteric bursitis. J. Bone Joint Surg. Br. 85, 199–203 (2003). 9. El Bitar, Y., Stake, C., Dunne, K., Botser, I. & Domb, B. Arthroscopic Iliopsoas Fractional Lengthening for Internal Snapping of the Hip: Clinical Outcomes With a Minimum 2-Year Follow-up. Am J Sport. Med 42, 1696–1703 (2014).

9. El Bitar, Y., Stake, C., Dunne, K., Botser, I. & Domb, B. Arthroscopic Iliopsoas Fractional Lengthening

for Internal Snapping of the Hip: Clinical Outcomes With a Minimum 2-Year Follow-up. Am J Sport. Med 42, 1696–1703 (2014).

10. De S A, D. et al. Ligamentum teres injuries of the hip: a systematic review examining surgical indications, treatment options, and outcomes. Arthroscopy 30, 1634–41 (2014).

11. Ebert, J. R., Bucher, T. a., Ball, S. V. & Janes, G. C. A review of surgical repair methods and patient outcomes for gluteal tendon tears. Hip Int. 25, 15–23 (2015).

12. Alpaugh, K., Chilelli, B. J., Xu, S. & Martin, S. D. Outcomes After Primary Open or Endoscopic Abductor Tendon Repair in the Hip: A Systematic Review of the Literature. Arthrosc. J. Arthrosc. Relat. Surg. 31, 530–540 (2015).

13. Kemp, J. L., MacDonald, D., Collins, N. J., Hatton, A. L. & Crossley, K. M. Hip Arthroscopy in the Setting of Hip Osteoarthritis: Systematic Review of Outcomes and Progression to Hip Arthroplasty. Clin. Orthop. Relat. Res. 473, 1055–1073 (2015).

14. National Institute for Health and Care Excellence. Technology appraisal guidance 304. Total hip replacement and resurfacing arthroplasty for end stage arthritis of the hip (review of technology appraisal guidance 2 and 44).

15. Marshall, D. a. et al. Hip Resurfacing versus Total Hip Arthroplasty: A Systematic Review Comparing Standardized Outcomes. Clin. Orthop. Relat. Res. 472, 2217–2230 (2014).

16. Pailhé, R. et al. Hip resurfacing: a systematic review of literature. Int. Orthop. 36, 2399–2410 (2012).

17. Qvistgaard, E., Christensen, R., Torp-Pedersen, S. & Bliddal, H. Intra-articular treatment of hip osteoarthritis: a randomized trial of hyaluronic acid, corticosteroid, and isotonic saline. Osteoarthr. Cartil. 14, 163–170 (2006).

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18. Lambert, R. G. W. et al. Steroid injection for osteoarthritis of the hip: A randomized, double-blind, placebo-controlled trial. Arthritis Rheum. 56, 2278–2287 (2007).

19. Atchia, I., Kane, D., Reed, M. R., Isaacs, J. D. & Birrell, F. Efficacy of a single ultrasound-guided injection for the treatment of hip osteoarthritis. Ann. Rheum. Dis. 70, 110–116 (2011).

20. Brinks, A., Bohnen, A. M., Verhaar, J. a N., Koes, B. W. & Bierma-zeinstra, S. M. a. Corticosteroid Injections for Greater Trochanteric Pain Syndrome : A Randomized. Ann. Fam. Med. 226–234 (2011). doi:10.1370/afm.1232.Department

21. National Institute for Health and Care Excellence. Clinical guidance 177. Osteoarthritis: Care and management in adults. (2014).

22. Furlong, C. Preoperative Smoking Cessation: A model to Estimate Potential Short Term Health Gain and Reductions in Length of Stay. A Report by the London Health Observatory. (2005).

Glossary

Abductor tendon: Tendons of the muscles in the buttocks.

Arthroscopy: Type of keyhole surgery used both to diagnose and treat problems with

joints

Acebatum: Part of the pelvis where the femur inserts.

Femoral head: Top of the femur (leg) bone).

Femoro-acetabular

impingement:

Condition where the bones of the hip are abnormally shaped causing

friction when they rub against each other.

Greater trochanteric

pain syndrome:

Syndrome defined by tenderness to palpation over the side of the hip.

Hip resurfacing: Replacement of damaged surfaces in the hip joint.

Labral tears: Tear of the ring of cartilage on the outside rim of the hip joint socket.

Ligamentum teres: Tendon connecting the head of the leg bone with the inside of the hip

joint.

Osteoarthritis: Condition where cartilage becomes damaged over time causing joints to

become painful and stiff.

Trochanteric bursitis: Inflammation of the trochanteric bursa in the hip.

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Pain relief services, - as per the Cambridgeshire and Peterborough Clinical Commissioning Group guidelines and Bedfordshire and Hertfordshire Priorities Forum

Policy: It is the responsibility of referring and treating clinicians to ensure compliance with this policy.

Services for pain relief need to be able to offer a wide range of therapies and are normally provided under the NHS. However, interventions where there is no evidence of effectiveness or of uncertain benefit, and requests for referral outside the area will not normally be provided under the NHS.

Definition: Pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage”. Chronic pain is common, affecting large numbers of the population. The causes of pain, and chronic pain in particular, are complex. Most patients should receive effective long-term therapy from their GP. Those who have pain that cannot be controlled with routine painkillers (analgesics) should be referred to a pain specialist (pain relief service) after or during appropriate investigations or treatments. Treatment of chronic pain needs to be provided as an integrated service, as there are often multiple causes, and a multidisciplinary approach is considered essential for its management.

Estimated number

of people affected:

The prevalence of pain in the general population is estimated to be between 7% to 10%. Furthermore, it is estimated that around 3.5% of the population are unable to lead a normal life because of pain and about 1% of the population is severely disabled. Examples of Interventions where evidence is weak:

Spinal cord stimulation.

Intravenous regional sympathetic blockade with guanethidine.

Resource

implications:

This policy does not change current practice, therefore the resource implications remain unchanged.

Health benefits: In most cases a complete cure is unlikely, but treatment is aimed to achieving a reduction in pain and/or an increase in activities and improved quality of life.

Risks: There is a chance of complications associated with, either during or following, surgical interventions. In addition, adverse reactions may follow drug treatment.

Priority: Interventions where the evidence suggests ineffectiveness or the evidence of efficacy is weak are considered a low priority, and will only be provided by the NHS in exceptional circumstances.

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GLOSSARY (ref 3) Transcutaneous: across the skin.

Spinal cord stimulation: technique using surgically implanted electrodes to activate mechanisms to inhibit pain.

Sympathetic nervous system:

part of the autonomic nervous system which regulates the functions of some of the internal organs independently of the will power.

Intravenous regional sympathetic blockade:

technique designed to block the sympathetic nervous system by injecting a high local concentration of a drug.

Guanethidine: a drug that acts by inhibiting the action of the sympathetic nervous system.

REFERENCES: 1. Halliday S. Services for Pain Relief. ACET report. April 1998.

2. McQuay, H et al. Systematic Review of Outpatient Services for Chronic Pain Control. Health Technology Assessment. Vol 1: No 6, Winchester, National Co-ordinating Centre for Health Technology Assessment 1997.

3. Black’s Medical Dictionary. 38th Edition. A & C Black. London. 1997.

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Pain relief services, - as per NW Surrey Clinicial Commissioning Group guidelines

Epidural Injections for Sciatica The CCG will fund lumbar transforaminal and caudal epidural injections for patients with radicular pain due to herniated disc (sciatica) when the following criteria have been met: • The patient has radicular pain (below the knee for lower lumbar herniations; into the anterior thigh for upper lumbar herniations) consistent with the level of spinal involvement OR • there is evidence of nerve-root irritation with a positive nerve-root tension sign (straight leg raise – positive between 30o and 70o positive femoral tension sign) • Symptoms persist despite some non-operative treatment for at least 3 weeks (e.g. analgesia, physiotherapy). Further Epidural injections should only be provided as part of a comprehensive pain management programme.

Facet joint injections Therapeutic The CCG will fund medial branch blocks for the management of cervical, thoracic and lumbar back pain as specified below: All conservative management options, (physiotherapy, exercise, pharmacotherapy including analgesia) have been tried and failed And the pain has resulted in moderate to significant impact on daily functioning The treatment of facet joint pain is provided as part of a comprehensive pain management programme Further facet joint injections will only be funded if the initial facet joint injection has had a proven therapeutic benefit and the patient is not suitable for Thermal Radiofrequency Denervation (RFD) or a Pain Management Programme (PMP). For those who are not suitable for RFD or PMP (patients with multiple co morbidities; cardiological and or respiratory dysfunction; cardiac pacemaker or other nerve stimulator; frail patients; elderly patients), up to two injections per year will be funded in line

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with the Pain Management Pathway for Chronic Facetal Pain. Intra articular injections will only be funded according to the criteria above. Note: (diagnostic facet joint injections used by spinal surgeons as part of a diagnostic pathway prior to making a decision to proceed to surgery will be funded).

Radiofrequency facet joint denervation (RFD) of lumbar and cervical facet joints for chronic facetal pain

Radiofrequency facet joint denervation of the medial branch of the dorsal rami of the lumbar and cervical facet joints (medial branch neurotomy) will be funded in the following circumstances: • Patients aged over 18 • Non-radicular lumbar (all levels) or cervical (C3-4 and below) facet joint pain. • Failure of a one year trial of non-invasive therapy, such as medication and physiotherapy. • One anaesthetic diagnostic block, which must be of the medial branch of the dorsal rami innervating the target facet joint. A significant reduction in pain following the block during activities that normally generate pain should be demonstrated and recorded. The pain relief must be consistent with the expected duration of the anaesthetic block. • All procedures must be performed under fluoroscopy (x-ray guidance). NICE Guidance ID CG 88 on ‘Low Back Pain’ iv indicates that radiofrequency facet joint denervation is not recommended for those with back pain of less than a year’s duration. Thermal radiofrequency denervation is provided as part of a comprehensive Pain Management Programme (PMP). Cryoneurolysis or laser denervation will not be funded. Up to four facet joint denervation’s on one occasion (one treatment episode) will be funded.

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