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Hip, knees and feet

Please see below for the policies relating to hips, knees and feet. To view the policy, patient leaflet and additional information, please click on the relevant heading.


  • Bunions

    What is the treatment for bunions?

    Bunions are bony lumps that form on the side of the feet. Bunions can be broadly classified into two: asymptomatic and symptomatic. The first one causes no pain but the second can be very uncomfortable.

    The symptoms of bunions include:

    • Hard lumps on the sides of the feet, by the big toes
    • Hard, red or swollen skin over the lump
    • Pain along the side or bottom of the feet (this is usually worse when wearing shoes and walking).

    Doctors don’t know exactly what causes bunions, but things that can increase the risk of developing them include:

    • Wearing ill-fitting shoes that adds a strain to the bones and muscles in the feet
    • The way a person walks, for example if the foot rolls inwards
    • Bunions can run in families
    • Bunions are sometimes associated with conditions that affect the joints, such as rheumatoidarthritis, gout, stroke or a foot injury
    • Being female may increase the risk due to tighter footwear being worn, wearing high heels, or because the structures that connect bones together in the feet (ligaments) are looser in women.

    Treatment

    A GP or podiatrist can offer advice about:

    • How to ease the symptoms, such as wearing wide shoes that don't squash the toes
    • Items to buy or have specially made which may help to reduce bunion pain, such insoles (orthotics), toe spacers and toe supports (splints).

    However, surgery is the only way to get rid of bunions so a GP may refer the patient to a surgeon if the bunions are very painful or are having a big effect on the patient's life.

    Patient eligibility criteria

    Surgery for asymptomatic bunions IS NOT routinely commissioned. If the patient has diagnosed diabetes and presents with an asymptomatic bunion the patient should be referred to a community foot health service.

    Surgery for symptomatic bunions will be funded in the following circumstances:

    • The patient has a confirmed diagnosis of a bunion, AND
    • The patient has deteriorating symptoms*, AND
    • ALL conservative measures** have failed after three months, AND
    • The patient is experiencing persistent pain and disability due to the bunion, which is causing functional impairment***, AND
    • The patient must be prepared to undergo surgery, understanding that they will be out of sedentary work for 2-6 weeks and physical work for 2-3 months and they will be unable to drive for 6-8 weeks (two weeks if left foot and driving automatic car), AND
    • Weight bearing X-rays have been undertaken prior to surgery, AND
    • The provider has adopted a shared decision making model, with defined treatment goals and has taken into account personal circumstances, with ALL alternatives discussed with the patient, AND
    • The procedure will be undertaken by orthopaedic surgeons trained in foot and ankle surgery or Health and Care Professions Council registered podiatric surgeons (CCPST), integrated into a multi-disciplinary network.

    * deteriorating symptoms are defined as moderate or severe pain AND functional impairment AND redness/soreness; OR bigger deformation, 2nd toe affected/lifting; OR callus under 2nd MTPJ.

    ** conservative measures are defined for the purposes of this policy as ensuring footwear is appropriate (low heels; wider fitting shoes; moulded shoes); AND the patient has been advised on and has trialled patient directed approach (bunion pads, over the counter analgesia, ice to relieve pain and inflammation orthotics); AND referral to podiatry for offloading orthotics has been exhausted; AND the patient has been provided with the patient leaflet.

    *** functional impairment is defined as interfering with activities of daily living, i.e. sleeping; eating; walking.

    Surgical correction of bunions using minimal access techniques IS NOT routinely commissioned in any circumstances due to limited information and the lack of long-term data about its effectiveness.

    This means (for patients who DO NOT meet the above criteria) the CCG will ONLY fund the treatment if an Individual Funding Request (IFR) application proves exceptional clinical need and that is supported by the CCG.

    Advice and further guidance

    • For more information, search for ‘bunions’ at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

    Or visit the following website:

  • Hip arthroscopy

    What is surgery for mismatch between the hip ball and socket?

    Mismatch or abnormal shape of the hip (femoro acetabular impingement or hip impingement), is an abnormal shape of the hip. It can be common amongst individuals who take part in sporting activities.

    There are two types of hip impingement, 'Cam' and 'Pincer' and you can get a combination of both. Normally the hip glides and moves smoothly as the ball shaped head of the thigh bone (femur) moves in the cup shaped hip socket (acetabulum).

    Cam Impingement is caused by a jamming or squeezing of an abnormally shaped head of the thigh bone (femoral head) and head-neck junction into the hip socket (acetabulum) during certain hip movements. Cam impingement typically occurs in young, athletic males.

    Pincer Impingement occurs when there is direct contact with the head of the thigh bone (femoral neck or head-neck junction) with part of the edge of the hip socket (acetabulum edge and labrum). The hip socket (acetabulum) appears to be 'over deep. 'Pincer impingement is more commonly seen in middle aged females.

    The presence of both types is referred to as mixed impingement.

    Symptoms include restriction of movement, ‘clicking’ of the hip joint, and pain. Symptoms may occur or increase during hip flexion activities (sometimes described as when the knee comes toward the chest) resulting from sporting activity, although many patients experience pain whilst sitting.

    Management of hip impingement usually includes a trial of conservative measures, including activity modification to reduce excessive motion and loading on the hip.

    Patients who do not improve with conservative treatment, may be considered for surgical management to improve range of movement and reduce pain may be required.

    Treatment

    The three surgical approaches commonly used are:

    • Open dislocation surgery involving dislocation of the hip joint
    • Arthroscopy (a surgical procedure that allows doctors to view the hip joint without making a large incision (cut) through the skin and other soft tissues) OR
    • Arthroscopy with a limited open approach.

    Compared to open surgery, there is evidence that the more limited open arthroscopic surgery is just as effective for reducing pain and improving function and quality of life for patients. It is also associated with lower rates of further operations being required.

    Patient eligibility criteria

    This is a very specialised procedure and needs to ONLY be undertaken by those who are undertaking a number of these procedures on a regular basis and have the clinical specialism and the Multi-Disciplinary Team (MDT - e.g. doctors, specialist nurses, physiotherapist) to support the patient in place.

    The CCG has commissioned certain hospitals with suitably qualified staff to undertake the procedure and the MDT in place to support the patient prior to, during and following surgery.

    Advice and guidance

    • For more information, search for femoroacetabular impingement at www.nhs.uk
    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.
  • Hip replacement surgery

    What is hip replacement surgery?

    A hip replacement is a common type of surgery where a damaged hip joint is replaced with an artificial one (prosthesis). The hip joint is one of the largest joints in the human body and is known as a ‘ball and socket joint’. In a healthy hip joint, the bones are connected to each other with bands of tissue (ligaments).

    The bands of tissue are lubricated with fluid to reduce friction. Joints are also surrounded by a type of tissue that is designed to help support the joints and prevent bones from rubbing against each other (cartilage).

    Many of the conditions treated with a hip replacement are age-related, so hip replacements are usually carried out in older adults aged over 60. However, there may be occasions, such as a severe hip fracture, where hip replacements may occasionally be performed in younger people.

    The purpose of a new hip joint is to:

    • Relieve pain
    • Improve the function of your hip
    • Improve your ability to move around
    • Improve your quality of life.

    Patient eligibility criteria:

    If supported by the patient's family doctor, then patient's local NHS commissioning organisation will only fund this treatment if the patient meets the following criteria:

    • Other options, such as medication, physiotherapy, walking aids, home adaptations and general counselling, have failed to help lessen the patients pain and disability; and
    • Does not respond to pain killer and loss of hip function is affecting the patients quality of life; and
    • The patient must accept and want surgery as the rehabilitation process after surgery can be a demanding time and needs commitment; or
    • The destruction of the patient’s joint is so severe that delaying surgery would increase the technical difficulty of the procedure.

    Should a patient meet the above criteria and be assessed as appropriate for surgery, if they have a BMI of 25 or more they will be actively supported to engage with local weight management programmes to reduce their BMI to improve the likelihood of a successful hip replacement. A patient's BMI alone however will not be a reason to prevent surgery happening.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    How hip replacement surgery is performed:

    A hip replacement can be carried out when the patient is asleep during the procedure (under general anaesthetic) or when the lower body is numbed (epidural). The surgeon makes an incision into the hip, removes the damaged hip joint and replaces it with an artificial joint made of a metal alloy or, in some cases, ceramic. The surgery usually takes around 60-90 minutes to complete.

    Alternative surgery:

    There is an alternative type of surgery to hip replacement, known as hip resurfacing. This involves removing the damaged surfaces of the bones inside the hip joint and replacing them with a metal surface. An advantage to this approach is that it removes less bone.

    However, it may not be suitable for:

    • Adults over the age of 65 years – bones tend to weaken as a person becomes older
    • Women who have gone through the menopause – one of the side effects of the menopause is that the bones can become weakened and brittle
      (osteoporosis).

    For more information, read the 'osteoarthritis of the hip decision aid' or search for ‘hip replacement’ www.nhs.uk

    • Choosing Wisely UK is part of a global initiative aimed at improving conversations between patients and their doctors and nurses.

    See separate leaflet for more information on Individual Funding Requests (IFRs).

  • Knee arthroscopy - acute knee injury

    The knee joint acts like a hinge to let you bend, straighten and move the leg. It is made up of three bones:

    • Thigh bone (femur)
    • Shin bone (tibia)
    • Kneecap (patella).

    Ligaments

    Ligaments are tough bands of connective tissue in the knee which join the thigh bone to the shin bone at the knee joint. They help keep the knee steady and balanced.

    Menisci

    The meniscus is a piece of cartilage – firm rubbery material. It covers the ends of the bones in the knee and helps to provide a cushion between your thighbone and shinbone. There are two menisci in each knee joint which help to:

    • Absorb impact from body weight
    • Improve movement
    • Support the stability of the knee.

    Acute knee injury:

    An acute knee injury is usually the result of a sudden twist, sprain, fall, force or direct bang to the knee. Common sports injuries can tear, damage or bruise the knee cartilage or ligaments. When they become damaged this can limit the knee’s normal movement and cause pain.

    Treatment:

    Treatment for acute knee injuries is generally conservative management, such as the PRICE protocol, medicines and physiotherapy.

    PRICE stands for Protection, Rest, Ice, Compression and Elevation which is effective pain andsymptom management for most sports-related injuries.

    • Protection – protect the affected area from further injury – for example, by using a support.
    • Rest – avoid exercise and reduce your daily physical activity. Using crutches or a walking stick may help if you can't put weight on your knee.
    • Ice – apply an ice pack to the affected area for 15-20 minutes every two to three hours. A bag of frozen peas, or similar, will work well. Wrap the ice pack in a towel so that it doesn't directly touch your skin and cause an ice burn.
    • Compression – use elastic compression bandages during the day to limit swelling.
    • Elevation – keep the injured body part raised above the level of your heart whenever possible. This may also help reduce swelling.

    Non-steroidal anti-inflammatory medicines like aspirin and ibuprofen can be used under medical guidance to reduce pain and swelling.

    Physiotherapy is offered to patients whose symptoms have not resolved after PRICE and taking medicines.

    Knee arthroscopy:

    A knee arthroscopy is a type of keyhole surgery which may be used to treat problems in the knee. A very small cut is made on the knee joint to insert a tiny camera (an arthroscope) so the inside of your knee can be seen on a monitor screen. This allows the surgeon to repair or trim any damage using small surgical tools.

    Meniscectomy

    This procedure involves removing some or all of the damaged or torn tissue.

    Reconstructive ligament surgery

    A torn ligament cannot be repaired by stitching it back together. However, it can be rebuilt by attaching new tissue from other areas of the leg.

    Risks

    There is a small risk of infection, worse pain, stiffness and damage to the nerves and blood vessels around the shoulder. In some cases, the surgery may need to be done again.

    Eligibility criteria:

    A knee arthroscopy for acute knee injury is a restricted surgical procedure. It is considered when other forms of treatment such as PRICE (Protection, Rest, Ice, Compression and Elevation), physiotherapy and painkillers after three months have not enabled knee function to be restored.

    The treatment will only be funded if a patient is under 35-years-old and:

    • Does not already have a degenerative knee disorder such as osteoarthritis

    AND

    • Continues to experience locking, clicking, popping or giving way of the knee

    AND

    • Has difficulties carrying out daily activities such as walking, sleeping or eating.

    This means the patient’s NHS commissioning organisation (CCG), who is responsible forbuying healthcare services on behalf of patients, will only fund the treatment if the patient meets the eligibility criteria above or an Individual Funding Request (IFR) application hasshown exceptional clinical need and the CCG supports this.

    Further guidance:

  • Knee replacement surgery

    What is knee replacement surgery?

    Knee replacement surgery involves replacing a damaged, worn or diseased knee with an artificial joint.

    More than 70,000 knee replacements are carried out in England and Wales each year, and the number is rising. A replacement knee lasts over 20 years, especially if the new knee is cared for properly and not put under too much strain. Most patients who have a total knee replacement are usually 65-years-old.

    There are two main types of surgery, depending on the condition of the knee:

    • Total knee replacement – both sides (back and front) of the patient’s knee joint are replaced
    • Partial (half) knee replacement – only one side (back or front) of the patient’s joint is replaced in a smaller operation with a shorter hospital stay and recovery period.

    The most common reason for knee replacement surgery is decline in the cartilage and bone (osteoarthritis). Other reasons include:

    • Long term condition causing pain, swelling and stiffness to the joints (rheumatoid arthritis)
    • Inability to clot blood (haemophilia)
    • Arthritis caused by acid crystal build up in the joints (gout)
    • Knee injury.

    A knee replacement is major surgery, so it is normally only recommended if other treatments, such as physiotherapy or steroid injections, haven't helped reduce pain or improved mobility.

    Patient eligibility criteria:

    If supported by your family doctor, your local NHS commissioning organisation will fund this treatment if the patient meets the top three bullet points, or the fourth bullet point:

    • Conservative means, including medication, physiotherapy, walking aids, home adaptations, and general counselling, have failed to alleviate the patients pain and disability; and
    • Severe pain unresponsive to pain relief medication and persistent loss of function affecting employment; and
      Patient must accept and want surgery (most total knee replacements are carried out on people between the ages of 60 and 80). The patient will need to be well enough to cope with both a major operation and the rehabilitation afterwards; or
    • The damage of the patient’s joint is so severe that delaying surgical correction would increase the difficulty of the procedure.

    If a patient meets the criteria and is assessed as appropriate for surgery, but they have a BMI of 25 or more, they will be actively supported to engage with local weight management programmes to reduce their BMI to improve the likelihood of a successful hip replacement. A patient's BMI alone however will not be a reason to prevent surgery happening.

    The clinician in charge of the care of the patient’s specific condition, usually a hospital doctor, can assist the application, if there is exceptional clinical need for the treatment to be funded. The patient’s clinician must evidence clinical exceptionality and must be supported by the patient’s local NHS commissioning organisation. See separate leaflet for more information on Individual Funding Requests (IFRs).

    Advice and further guidance:

    Knee replacement surgery is usually performed either under general anaesthetic (the patient is asleep throughout the procedure) or under spinal or epidural anaesthetic (the patient is awake but has no feeling from the waist down).

    The worn ends of the bones in the patient’s knee joint are removed and replaced with metal and plastic parts (a prosthesis) which have been measured to fit. The patient may have either a total or a half-knee replacement. This will depend on how damaged the patients knee is. Total knee replacements are the most common.

  • Arthroscopic surgery for meniscal tears

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