Hip Arthroscopy – Criteria Led Commissioning Statement

Scope

This commissioning statement refers to

  • Arthroscopic Femoro-Acetabular surgery for Hip impingement Surgery (Hip Arthroscopy)

This commissioning statement does not refer to:

  • Red flag symptoms or signs which include:
    • Recent trauma, constant progressive non-mechanical pain (particularly at night)
    • Previous history of cancer, long term oral steroid use
    • History of drug abuse or HIV, fever, being systematically unwell,
    • Recent unexplained weight loss, persistent severe restriction of joint movement, widespread neurological changes, and structural deformity.
    • infection, carcinoma, nerve root impingement, bony fracture and avascular necrosis

Status

Eligibility Criteria

Current evidence on safety and efficacy does not appear adequate to recommend hip arthroscopy other than as listed below. On this basis, the CCGs would not routinely support Hip Arthroscopy.

The commissioning of hip arthroscopy (from surgeons with specialist expertise in this type of surgery) is in line with the requirements stipulated by NICE IPG 408 and only for patients who fulfil ALL of the following criteria:

  • A definite diagnosis of hip impingement syndrome /femoro-acetabular impingement (FAI) has been made by appropriate investigations, X-rays, MRI and CT scans
  • An orthopaedic surgeon who specialises in young adult hip surgery has made the diagnosis in collaboration with a specialist musculoskeletal radiologist
  • The patient has had severe FAI symptoms (restriction of movement, pain and 'clicking') or significantly compromised functioning for at least 6 months
  • The symptoms have not responded to all available conservative treatment options including activity modification, drug therapy (NSAIDs) and specialist physiotherapy

Patients should make shared decisions with clinicians, using decision support such as the NHS Decision Aid for Hip osteoarthritis

Lifestyle Factors - Best Practice

Obesity

  • Patients with a BMI >30 should be encouraged by their Clinician to lose weight prior to surgery and signposted to appropriate support to address lifestyle factors that would improve their fitness for surgery and recovery afterwards.
  • There is a clinical balance between risk of surgical complications with obesity and the risk to delaying any surgery.
  • See Weight Management Care Pathways

Smoking

  • In line with 'Healthy Lives, Healthy People; a tobacco control plan for England', local authorities and health professionals are committed to encourage more smokers to quit.
  • Smoking remains the leading cause of preventable morbidity and premature death in England.
  • There is sufficient evidence to suggest that people who smoke have a considerably increased risk of intra- and post-operative complications such as chest infections, lung disorders, wound complications and impaired healing.
  • See Smoking Cessation Care Pathways
Please Note: The life style factors above are not a restriction to the commissioning statements unless otherwise stated

Evidence/Rationale

Hip impingement syndrome is caused by abnormal contact between the top of the thigh bone and the hip socket. This results in 'clicking' of the hip, limited movement and pain, which can be made worse when the hip is bent or after sitting for a long time. The condition may be caused by an unusually shaped thigh bone or hip socket and usually affects young, often active people. Hip impingement syndrome is usually managed by changes to lifestyle and drug treatment. Treatment via hip arthroscopy has evolved greatly in the last decade with improvements in the available technology, and in Sept 2011 NICE issued IPG 408 on arthroscopic femoroacetabular surgery for hip impingement syndrome. The aim of the procedure is to reduce pain and improve the hip-joint range of movement. With the patient under general anaesthetic, a thin telescope (arthroscope) is inserted into the hip joint through a small cut in the skin. The surgeon then makes further cuts and uses instruments to remove some of the cartilage and/or bone in order to reshape the joint surfaces.

The guidance states that that current evidence on the efficacy of this treatment is adequate in terms of symptom relief in the short and medium term and may possibly delay progression to osteoarthritis. In terms of safety it states that complications (which occur in up to 5% of cases) are 'well recognised', usually adverse events relating to the significant traction required during the technically demanding procedure. The guidance stipulates that details of all patients undergoing this procedure should be entered into a register established by the British Hip Society.

NICE concludes that despite some methodological drawbacks in the studies, no RCT evidence, and the paucity of evidence on treatment outcomes beyond two years, the available efficacy evidence appears adequate, key outcomes for this procedure include improved function and quality of life, pain relief and delayed progression to osteoarthritis in some patients

References

  1. NICE IPG 408 (Sept 2011) Arthroscopic femoro-acetabular surgery for hip impingement syndrome http://guidance.nice.org.uk/IPG408
  2. Vijay D Shetty, Richard N Villar. Hip arthroscopy: current concepts and review of literature. Br J Sports Med 2007;41:64–68. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2658928/pdf/64.pdf
  3. Macfarlane RJ, Haddad FS The diagnosis and management of femoroacetabular impingement. Annals of the Royal College of Surgeons of England, July 2010, vol./is. 92/5(363-7) http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3180305/pdf/rcse9205-363.pdf
  4. Ng V Y et al. Efficacy of Surgery for Femoro-acetabular Impingement: A Systematic Review. Am J Sports Med November 2010 38 2337-2345 http://www.ncbi.nlm.nih.gov/pubmed/20489213

Assurance & Governance

  • This policy was developed on: 05.2017
  • This policy was approved by: Clinical Strategy Group (NK) and Clinical Cabinet (WK)
  • Date approved: 05.2017
  • Publication Date: 05.2017
  • Review Date: 04.2018
  • Ref No: PA5 - 05.2017
Any feedback or suggestions to improve this guidance should be sent to: oscaradmin@this.nhs.uk
Only the electronic version is maintained, once printed this is no longer a controlled document

 

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