Femoro–Acetabular Impingement, open or arthroscopic surgery

This is a summary of the NEW Devon CCG commissioning policy for open or arthroscopic surgery for the treatment of femoro–acetabular impingement (FAI)

Management

Non operative treatment of FAI includes rest, physiotherapy, and activity modification to reduce unnecessary hip motion, rest, anti-inflammatory medication and core strengthening, proceeding to surgery if symptoms persist.

However although these are the usual first line treatment in musculoskeletal injuries, their benefits are questioned in FAI and with recommendation of corrective surgery in all FAI diagnosed patients to avoid delay which could result in disease progression to the point where joint preservation is no longer possible.

Referral

Referral Criteria

Commissioning decision

Open or arthroscopic surgery for the treatment of femoro-acetabular impingement will be routinely commissioned only for patients who fulfil all 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 month time frame, or where failure to treat early is likely to significantly compromise surgical options at a future date.
  • Aged between 18 and 50 years (clinical experience has shown that these patients are likely to gain the greatest benefit).

Patients not included in these criteria are:

  • Patients with advanced osteoarthritis change on preoperative x-ray (Tonnis grade 2 or more) or severe cartilage injury (Outerbridge grade III or IV).
  • Patients with a joint space on plain radiograph of the pelvis that is less than 2mm wide anywhere along the sourcil.
  • Patients who are candidates for total hip replacement.
  • Patients who have hip dysplasia.
  • Patients with generalised joint laxity especially in diseases connected with hypermobility of the joints, such as Marfan syndrome and Ehlers-Danlos syndrome.
  • Patients with osteogenesis imperfecta.

Patients undergoing hip arthroscopy are subject to prospective study using validated scores. Standard data on perception of pain and interference in daily living are requested to accompany the prior notification form. A consistent reasonable data collection as decided by the clinical team is required in order to get consistency in use of outcome measures e.g. Oxford Hip Scores or Non arthritic Hip Scores

Open or Arthroscopic Surgery for the Treatment of Femoro-acetabular Impingement Commissioning Policy

Referral Instructions

Prior approval is not required for patients being treated in accordance with this policy, although a Prior Notification form (example enclosed) should continue to be sent to the Exceptional Treatments Panel at the time a decision to treat is made.

If the patient does not meet all the criteria described above but the clinician still feels that this treatment is recommended then a funding request should be made in the normal manner.

Treatment of FAI should be restricted to centres experienced in treating this condition and staffed by surgeons adequately trained in techniques addressing FAI and all governance and audit undertaken in accordance with NICE IPG 403 and IPG 408.

Applications for consideration for funding approval should be sent to:

Email: d-ccg.ifr-newsdt@nhs.net

Alternatively, please send to: The Panel administrator at Bridge House, Collett Way, Newton Abbot, TQ12 4PH

Supporting Information

 

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